TRANSTRACHEAL CYANOACRYLATE GLUE INJECTION FOR THE MANAGEMENT OF MALIGNANT TRACHEOESOPHAGEAL FISTULA

A 56-year-old man presented with complain of intractable cough on swallowing for last 3 months. He had completed a course of chemoradiotherapy for carcinoma of middle one third of oesophagus four months back. The upper gastrointestinal endoscopy showed stricture at 23 cm in oesophagus. A small (˜ 4 mm diameter) fistula was noted just above stricture. Application of over-the-scope clip failed. A hydrophilic guide wire (0.032” inches diameter) was placed through the ERCP cannula into the fistula. Bronchoscopy revealed the presence of guidewire coming out from a fistulous tract in the posterior wall of the trachea above the tracheal bifurcation. The guide wire was grasped with a biopsy forceps. The guide wire was removed along with the scope from the mouth. The fluoroscopic image showed a curved course (length of the fistula was about 2.5 cm) of the guide wire. After assessment of the fistula by the track of the guidewire, two routes of glue injection were considered, Trans-tracheal and Trans-esophageal. Transesophageal route was considered risky due to an expected spillage of the glue within the trachea. Hence, the option of transtracheal glue injection was selected. The cannula and the scope were reintroduced through the trachea. The presence of the markers on the cannula were used to assess the depth of insertion of cannula within the fistula and to plan the site of injection of the glue. 1 ml of cyanoacrylate glue was injected while pulling the cannula out. 1 ml of distilled water was injected while pulling out the rest of the cannula to the tip of the fistula. After one hour, the patient started swallowing liquids without any cough. Patient has remained asymptomatic till now.

Conclusion:

Transtracheal glue placement may be safer than transoesophageal glue placement. This appears to be first report of transtracheal glue injection of malignant TEF.