Xin-Di Zhang, Yang Bai
Background: Malignant tracheoesophageal fistula (mTEF) is a life-threatening complication of esophageal and lung cancers, often presenting significant management challenges, especially in post-radiotherapy patients with anatomical airway distortion. This case report describes a feasible modified approach for closing a cervical mTEF with anatomical airway distortion that precludes laryngeal mask airway (LMA) placement or rigid bronchoscopy. This approach utilizes thin bronchoscope-parallel, endotracheal tube (ETT)-guided stent deployment, without the need for fluoroscopy. Case presentation: A 79-year-old male with a 5-year history of stage IIIB (T3N1M0) thoracic esophageal squamous carcinoma (post-definitive chemoradiation and pembrolizumab immunotherapy with complete response) presented with 20 days of swallowing-induced immediate cough (Ono's sign), purulent yellow sputum (30 mL/day), exertional dyspnea (New York Heart Association Class II), and subsequent fever. Diagnostic workup confirmed a cervical mTEF 5 cm below the glottis, with post-radiation airway stiffness precluding LMA placement or rigid bronchoscopy. Under general anesthesia, a 7.5-mm cuffed ETT was positioned 1 cm above the fistula under direct bronchoscopic visualization with real-time distance measurement, and a 3.8-mm thin bronchoscope was inserted in parallel to provide real-time visualization for the stent deployment. An 18-Fr delivery system with a 20 mm (diameter) × 40 mm (length) partially covered Ultraflex metallic stent was deployed via the ETT, achieving immediate and complete mTEF closure. Anesthesia was maintained with propofol-remifentanil infusion and volume-controlled ventilation (tidal volume 6 mL/kg, respiratory rate 16/min, fraction of inspired oxygen 50-60%) with continuous oxygen saturation and end-tidal carbon dioxide monitoring. The patient was extubated promptly, transitioned to oral feeding, and remained aspiration-free for 3 months with no complications. He developed recurrent coughing at 3 months post-procedure and died after declining further treatment. Conclusion: This single-stage, fluoroscopy-free ETT-parallel thin bronchoscope approach demonstrates preliminary feasibility and short-term safety for high cervical mTEF in post-radiotherapy patients with anatomical airway distortion where LMA or rigid bronchoscopy is unfeasible. Individualized airway management, precise stent selection, and multidisciplinary collaboration are critical for optimizing symptom control, and this approach might serve as a practical short-term palliative alternative in resource-limited settings. These findings are hypothesis-generating and require validation in larger studies.