A Complicated Parenchymal-Esophageal Fistula in Non-Small Cell Lung Cancer

Respiratory digestive fistula (RDF) is an abnormal communication between the airway and the digestive tract. Only 3-11% of RDF communications are parenchymal-esophageal fistulas. We present a case of a 58-year-old male who presented to the emergency department with dysphagia and cough after swallowing. He was diagnosed with stage III/B non-small cell lung cancer. The patient was previously treated with chemotherapy, radiation, and immunotherapy. Computed tomography (CT) scan of the chest with contrast showed a chronic cavitary right upper lobe lesion in the previously treated malignancy area. New right paratracheal adenopathy, right esophageal wall thickening, and bilateral lung infiltrates were also shown. Upper endoscopy with bronchoscopy and endobronchial ultrasound (EBUS) was done to evaluate mediastinal lymphadenopathy as well as dysphagia. A tract was found extending from the right lung cavity into the esophagus through the mediastinum. Esophagoscopy was subsequently performed, and a fistula was observed on the right wall of the mid-esophagus. The defect was favorable for clipping, which was successfully closed with an 11/6 traumatic over the scope clip, followed by a fully covered esophageal stent. The patient's respiratory and gastrointestinal symptoms improved after the procedure. Follow-up barium swallow was negative for any esophageal leak. At three-month follow-up, the patient was free of recurrent pulmonary and gastrointestinal symptoms that he presented with. Palliative therapy is the targeted therapy for RDF management. RDF is either managed conservatively or with radiation, chemotherapy, or surgery to obliterate the connection. Surgical correction usually is not an option since patients typically have a poor functional status at the time of diagnosis. Considering the survival and recurrence rate medical intervention is the mainstay of treatment. Parallel dual (esophageal-bronchial) stenting has been proven to provide the best outcomes. Self-expanding metal stents (SEMS), either covered or partially covered, are used extensively to manage malignant RDF.