case_images: PMC9729335_01
case_images: (A) Sagittal chest computed tomography (CT) view showed the severe granulation tissue hyperplasia on the upper edge of the covered self-expandable metallic stent (SEMS) and the shearing force against the anterior esophageal wall (white arrow). (B) Axial chest CT view showed severe granulation tissue hyperplasia and tracheoesophageal fistula (TEF) (black arrow) on the upper edge of the SEMS. (C) The bronchoscopy confirmed severe granulation tissue hyperplasia on the upper edge of the covered SEMS, causing 90% airway obstruction. (D) The bronchoscopy identified the TEF (white arrow) located in the 7 o'clock position after eradicating the severe granulation tissue hyperplasia.
case_images: fmed-09-996140-g001.jpg
case_images: PMC9729335_01_fmed-09-996140-g001.jpg
case_images: F1
case_images: The chest computed tomography (CT) demonstrated severe granulation tissue hyperplasia on the upper edge of the covered SEMS, inducing the shearing force against the anterior esophageal wall (Figure 1A), and a part of the stent penetrated the esophagus (Figure 1B). The bronchoscopy confirmed severe granulation tissue hyperplasia on the upper edge of the covered SEMS, causing 90% airway obstruction (Figure 1C). After eradicating the granulation tissue, the TEF was located in the 7 o'clock position (Figure 1D).
case_images: (A) Endoscopy showed the covered self-expandable metallic stent (SEMS) was partially embedded in the esophagus through the tracheoesophageal fistula (TEF). (B) The embedded part of the stent was vaporized with the neodymium-doped yttrium aluminum garnet laser (white arrow) through the esophagus. (C) The covered Y-shape SEMS was removed via rigid bronchoscopy in a piecemeal fashion. (D) The bronchoscopic view of the TEF (white arrow) and complex post-tuberculosis tracheobronchial stenosis (PTTS) in the trachea.
case_images: fmed-09-996140-g002.jpg
case_images: PMC9729335_01_fmed-09-996140-g002.jpg
case_images: F2
case_images: SEMS via bronchoscopic intervention because the surgical repair was impossible and deemed high risk. Since the stent was partially embedded in the esophagus (Figure 2A), we vaporized this embedded part with the neodymium-doped yttrium aluminum garnet laser (Figure 2B). The covered Y-shape SEMS was removed via rigid bronchoscopy in a piecemeal fashion (Figure 2C) under general anesthesia, revealing the TEF and complex PTTS in the trachea (Figure 2D). The whole procedure was completed in concert with cardiothoracic surgery backup.
case_images: (A) The chest computed tomography (CT) showed the tracheoesophageal fistula (TEF) in the trachea (black arrow). (B) The chest CT performed after the stent removal demonstrated a diffuse tracheal stenosis, the narrowest part being 5.7 mm in diameter (black arrow). (C) Axial chest CT view confirmed the closure of TEF and patency of the trachea (black arrow). (D) The fully covered self-expandable metallic stent extended more than 10 mm beyond the TEF to occlude the orifice and establish the patency of the tracheobronchial tree. (E) The endoscopic view of TEF was fully covered by epithelium and granulation tissue (white arrow).
case_images: fmed-09-996140-g003.jpg
case_images: PMC9729335_01_fmed-09-996140-g003.jpg
case_images: F3
case_images: TEF (Figure 3A), associated with complex PTTS, with the narrowest part being 5.7 mm in diameter (Figure 3B), unsuitable for surgical repair or rigid bronchoscopy (which could increase the risk of TEF orifice and establish the patency of the tracheobronchial tree (Figure 3C) on a compassionate basis. TEF (Figure 3D). The local administration of recombinant bovine basic fibroblast growth factor (rbFGF) (Beifuji Spray, Essex Bio-Pharmaceutical Co., Ltd.; 6,000 IU/time) was sprayed into and around the fistula through the esophagus using the bronchoscope every other week as we reported (for a total of 4 times). The TEF was closed 3 months after inserting the fully covered Y-shaped SEMS and covered by epithelium and granulation tissue (Figure 3E) in endoscopy. The gastrostomy tube was removed when the patient started with normal feeding. The patient received routine bronchoscopy and removal of granulation tissue on the edges of the SEMS every 2-weeks to maintain the stent patency and reduce the risk of stent-related TEF. She showed sustained clinical and radiographic improvement in the follow-up up to 1.5 years after the treatment.