Three-Dimensional Printing-Assisted, Double-Y-Shaped Stent for the Treatment of a Giant Bronchoesophageal Fistula

Bronchoesophageal fistulas (BEFs) are a life-threatening condition that can lead to intractable pulmonary infection and respiratory failure. Placement of esophageal stents has become the most commonly used method for the treatment of BEFs (1Brunner S. Bruns C.J. Schröder W. Esophagotracheal and esophagobronchial fistulas.Chirurg. 2021; 92: 577-588Crossref PubMed Scopus (1) Google Scholar). However, when the fistula is large, the esophageal stent can prolapse into the airway and cause obstruction (2Zhou C. Hu Y. Xiao Y. Yin W. Current treatment of tracheoesophageal fistula.Ther Adv Respir Dis. 2017; 11: 173-180Crossref PubMed Scopus (32) Google Scholar). To avoid this situation in a patient with a giant BEF, 3-dimensional (3D) printing was used to assist with the placement and docking of 2 covered, Y-shaped, flexible connection, metal airway stents in vivo. Consent was obtained from the patient for publication of this article, and the report was approved by the ethics committee of the authors’ center. A 79-year-old male patient with squamous cell carcinoma of the midesophagus developed choking after eating following chemotherapy and radiotherapy. A chest computed tomography (CT) scan (Fig 1) and bronchoscopy (Fig 2) revealed a large BEF and associated pneumonia. A 3D-printed model of the esophagus and airway was fabricated based on the CT scan (Fig 3); in vitro, simulated placement of an esophageal stent revealed stent malapposition and protrusion into the left main bronchus, leading to bronchial obstruction. Because the fistula was very large (3.8 × 2.0 cm), 2 covered, Y-shaped, flexible, metal airway stents were chosen to be implanted. Two stiffened guide wires were inserted into the left and right lower lobe bronchi, and a large, Y-shaped stent (trachea to the right main bronchus to the left main bronchus) was deployed. The right guide wire was repositioned into the left upper lobe bronchus, and a smaller, Y-shaped stent (left main bronchus to the left upper lobe bronchus to the left lower lobe bronchus) was deployed, overlapping the left limb of the tracheobronchial stent (Fig 4). Three days after the procedure, CT (Fig 5) and bronchoscopy confirmed the position of the stents, excluding the fistula with preserved airway patency. Esophagography (Fig 6) showed no leakage of the contrast agent into the airway, and the patient resumed oral feeding. At 3 months of follow-up, the patient was free of choking, pneumonia had resolved, and the stent remained in position, without obstructive granulation tissue or hyperplasia.Figure 2A bronchoscopic view from the trachea showed the nasogastric tube in the esophagus (arrow) visible through the bronchoesophageal fistula.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3A posterior view of the 3-dimenional-printed model of the bronchoesophageal fistula (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Two overlapping Y-shaped airway stents were placed, 1 in the trachea, extending into each main bronchus (black arrow), and the other in the left main bronchus, extending into the left upper and left lower lobe bronchi (white arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Coronal reconstruction of a computed tomography scan performed 3 days after stent placement showed that the stents were stable in the intended positions and well apposed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6An esophagogram 3 days after stent placement showed no leakage into the airway and preserved deglutition function.View Large Image Figure ViewerDownload Hi-res image Download (PPT) 3D printing has proven to be useful in the study of airway structure and function. Airaiyes et al (3Airaiyes A.H. Avasaraia S.K. Machuzak M.S. Gildea T.R. 3D printing for airway disease.AME Med J. 2019; 4: 14Crossref PubMed Scopus (12) Google Scholar) customized airway stents for patients with complex airway diseases to reduce stent displacement, fractures, and restenosis caused by stent size mismatch. Huang et al (4Huang W. Shan Q. Wu Z. et al.Retrievable covered metallic segmented Y airway stent for gastrorespiratory fistula of carina or main bronchi.J Thorac Cardiovasc Surg. 2021; 161: 1664-1671Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar) developed a recyclable airway stent based on 3D printing for the treatment of a thoracic gastric airway fistula after an esophageal cancer surgery, wherein the structure of the stent was tailored to that of the airway. In the current report, a 3D-printed model of the esophagus and trachea allowed bench-top testing that portended poor apposition of an esophageal stent, with prolapse into the left main bronchus, leading to a change of plan to placement of airway stents instead. In conclusion, a 3D-printed model assisted in the simulation, planning, and placement of 2 overlapping, Y-shaped airway stents, successfully closing a giant BEF while maintaining patency and function of both the esophagus and airways. The authors thank MicroPort Nanjing for its help in the preparation of airway stents. This study was supported by the Henan Province Natural Science Foundation Youth Project (grant number 222300420349).