Transtracheal cyanoacrylate glue injection for the management of malignant tracheoesophageal fistula

BACKGROUND: Malignant tracheoesophageal fistula (TEF) is a devastating complication of esophageal cancer, lung cancer, or other carcinoma associated with high mortality, short survival, and poor quality of life. Covered metallic stents placement either in trachea/esophagus or both are used for the palliative treatment. Other endoscopic modalities rarely attempted for benign and malignant TEF include use of over the scope clip, transesophageal glue injection, electrocautery, and laser. CASE DESCRIPTION: A 56-year-old man presented with complaint of intractable cough on swallowing for last 3 months. He had completed a course of chemo-radiotherapy for carcinoma of middle one-third of the esophagus 4 months back. The upper gastrointestinal endoscopy showed a stricture with superficial ulceration at 23 cm from lower incisor in the esophagus. A small (~4 mm diameter) fistula was noted just above the stricture. Application of over-the-scope clip was failed. A hydrophilic guide wire (0.032″ diameter) was placed through the ERCP cannula into the fistula. Bronchoscopy revealed the presence of guidewire coming out from a fistulous tract in the posterior wall of the trachea above the tracheal bifurcation. The guide wire was grasped with a biopsy forceps. The guidewire was removed along with the scope from the mouth. The fluoroscopic image showed a curved course (length of the fistula was about 2.5 cm) of the guidewire. After assessment of the fistula by the track of the guidewire, two routes of glue injection were considered, transtracheal and transesophageal. Transesophageal route was considered risky due to an expected spillage of the glue within the trachea. Hence, the option of transtracheal glue injection was selected. The cannula and the scope were reintroduced through the trachea. The presence of the markers on the cannula was used to assess the depth of insertion of cannula within the fistula and to plan the site of injection of the glue. 1 mL of cyanoacrylate glue was injected while pulling the cannula out. 1 mL of distilled water was injected while pulling out the rest of the cannula to the tip of the fistula. After one hour, the patient started swallowing liquids without any cough. The patient has remained asymptomatic till now. CONCLUSION: Transtracheal glue placement may be safer than transesophageal glue placement. This appears to be the first report of transtracheal glue injection of malignant TEF.