A 67-years-old male patient was diagnosed with locally advanced non-small cell lung cancer (NSCLC) (clinical oncological staging: T3 N3 M0) with subcarinal lymph node metastasis causing esophageal compression. [18F]Fluorodeoxyglucose (FDG)-positron emission tomography (PET) confirmed an increased metabolic activity on the lower left lobe, site of the primary neoplastic tissue, and in correspondence with the metastatic lymph nodes at the level of the esophageal stenosis [standardized uptake value (SUV) max 10.2]. Considering the dysphagia reported by the patient, esophagogastroduodenoscopy (EGDS) was performed showing a 6 cm long intrinsic neoplastic stenosis in the caudal part of the esophagus. A fully covered metal esophageal stent was then positioned, leading to dysphagia resolution. After a multidisciplinary discussion with oncologist and radiotherapist, concomitant radiotherapy and chemotherapy (cCRT) was started. After the treatment, a restaging with computer tomography (CT)-scan and FDG-PET was performed, and a partial response (PR) was defined based on Response Evaluation Criteria in Solid Tumor (RECIST).
After a 17-months follow-up without disease progression, the patient developed cough, chest pain and pneumonia. The patient underwent chest CT-scan, which detected the development of TEF and inhaled pneumonia.
Urgent bronchoscopy was performed showing a roughly 3 cm x 1 cm TEF superior to the carina with the esophageal stent protruding into the tracheal lumen (Figure 1). A multidisciplinary discussion was made including bronchoscopists, otolaryngologists, plastic surgeons and anesthesiologists. Surgical correction was excluded due to high operative risk. However, given the patient's life expectancy after cCRT and the absence of disease progression after 17 months from treatments, an alternative procedure was proposed to allow the reconstruction of the tracheal laceration avoiding the progression of TEF secondary to a double stenting. The multidisciplinary team expressed consensus over a bronchoscopic repair of TEF with autologous fascia lata was decided, but without the removal of the esophageal stent due to the high risks on the esophagus such a procedure would have involved.
General anesthesia was induced and spontaneous breathing mantained. A Dumon rigid bronchoscope was employed (Efer Medical, La Ciotat, Cedex, France). A 5 cm long incision was performed along the lateral aspect of the caudal part of the thigh and a fascia lata graft of roughly 7 cm x 3 cm and 6 mm in thickness with subcutaneous fat tissue was harvested to obtain sufficient graft thickness (Figure 1).
Under bronchoscopic guidance TEF was identified and margins were freshened using a suction instrument. Synthetic biodegradable cyanoacrylate glue (Glubran 2;GEM) was injected on the edges of the tracheal laceration using a syringe via 5 Fr angioplasty catheter [Angiographic Catheter Tempo   Vertebral (VERT) Ref. 451-514H0 Cordis  ] to create an elastic film on the posterior wall of the trachea and facilitate graft adhesion to the surrounding tissue. The fascia lata graft was taken with endoscopic forcep and positioned in the tracheal lumen passing through the rigid bronchoscope. The whole defect was fully covered with subcutaneous fat facing the esophageal stent and fascial side facing the tracheal lumen.
During graft placement, spontaneous breathing was suppressed in order to avoid fascia lata displacement.
A silicone tracheal stent (NOVATECH Dumon stents, ST 18-16-18 L 15-20-15, Boston Medical Products, Inc., Westborough, MA, USA) was placed to maintain the fascia lata graft in place allowing to cover TEF site both cranially and caudally (Figure 2). Flexible bronchoscopy was performed at the end of surgery in order to check the adequate graft placement.
Videofluoroscopy was performed 1 week after the procedure showing no signs of TEF patency (Figure 3).
Oral feeding was progressively introduced after 2 days. No aspiration symptoms were referred.
Videofluoroscopy and EGDS were performed after 7 months showing no signs of TEF patency. EGDS showed esophageal stent and fascia lata in place (Figure 3) with the patient maintaining oral feeding without any weight loss or aspiration symptoms or signs.