Abstract Background Bronchoesophageal fistula (BEF) is an abnormal connection between the tracheobronchial tree and the esophagus. Common causes include malignancy, infection, trauma, and iatrogenic injury from esophageal stenting.1,2 Esophageal stents are frequently used for palliation of malignant obstruction, but can lead to perforation in 1-4% of cases3 and BEF in 4-15% of cases.3-5 Stent-associated BEF typically develops a median of five months after placement and is most often seen in patients with proximal or mid-esophageal tumors and prior radiation exposure.5,6 This case is atypical in that the patient’s primary tumor was distal and fistulization occurred 15 months after stenting. BEF is frequently misdiagnosed as pneumonia or drug-induced pneumonitis, underscoring the need for a high index of suspicion even when anatomy and timing seem less suggestive. Case A 56-year-old man with metastatic distal esophageal adenocarcinoma, status-post esophageal stenting 15 months earlier and esophageal radiotherapy 6 months ago, presented with three days of dyspnea and productive cough. CT imaging showed a well-positioned esophageal stent abutting the right mainstem bronchus (RMS) and bilateral ground-glass opacities (Panels A-B), initially read as possible drug-induced pneumonitis given recent nivolumab and trastuzumab deruxtecan exposure. He received empiric antibiotics, then corticosteroids for possible pneumonitis. His respiratory status worsened, with recurrent postprandial cough and hypoxemia, prompting transfer to the ICU and endoscopic evaluation. EGD revealed esophageal necrosis and a BEF from stent erosion into the RMS (Panels C-D), confirmed on fluoroscopy (Panel E) and bronchoscopy (Panel F). To avoid further perforation, the original stent was left in place and a second overlapping stent was deployed, though it did not fully seal the defect. Airway stenting was deferred due to concern that opposing stents would worsen erosion. After goals-of-care discussions, the patient elected for nasojejunal feeding and home hospice.Take-Home Points: This case highlights bronchoesophageal fistula (BEF) as an uncommon but serious complication of esophageal stenting. The close proximity of the proximal esophagus to the right main bronchus predisposes it to ischemia and mechanical injury from chronic stent pressure. BEF should be suspected in patients with new cough, recurrent aspiration, or unexplained respiratory decline after stent placement.Diagnosis is best achieved with contrast-enhanced imaging plus coordinated endoscopic and bronchoscopic evaluation. Management is individualized and may include endoscopic or bronchoscopic interventions, but successful outcomes depend on early recognition and multidisciplinary planning. This abstract is funded by: n/a
Ainte et al. (Fri,) studied this question.