Endoscopic Approach to Tracheoesophageal Fistulas in Adults

Tracheoesophageal fistulas (TEF) in adults are primarily of malignant etiology with esophageal and lung cancers being the most common. Most cases of benign TEF have iatrogenic causes. Historically, the recommended treatment of TEF was surgical. Although this is still the case for benign TEF, endoscopic stent insertion is currently the recommended approach for malignant TEF, as well as benign TEF when the surgical approach must be deferred. Since the mid-1990s self-expanding metal stents (SEMS) have replaced rigid plastic prosthesis as the stent of first choice. SEMS close 89% of TEFs, although the rate of recurrence has been reported as high as 35%. Some patients require stents in the trachea as well as the esophagus to achieve complete closure of the TEF. In others, tracheal stents alone are sufficient. The recently introduced self-expanding plastic stents (SEPS) are more readily removed than most SEMS and have a role in treating benign TEF. SEPS role in malignant TEF is being defined. Stent selection and placement technique are reviewed for various clinical scenarios.