Trakeoözofageal Fistüllerde Tanı ve Tedavi Yaklaşımı
Özet
Trakeoözofageal fistül (TÖF), özofagus ile trakea arasındaki patolojik bağlantı olup yetişkinlerde genellikle özofagus veya akciğer kanseri gibi malign nedenlerle gelişir. Katı-sıvı alımı sonrası öksürük, tekrarlayan bronşit, pnömoni ve malnütrisyon en belirgin klinik özellikleridir. Tanı aşamasında baryum kontrastlı özofagogram, bilgisayarlı tomografi, bronkoskopi ve endoskopi yöntemlerinden yararlanılır. Tedavi yönetimi gastroenteroloji, göğüs cerrahisi ve onkoloji gibi disiplinlerin katılımıyla multidisipliner bir yaklaşım gerektirir. Malign TÖF vakalarında spontan kapanma nadir olduğundan semptomları hafifletmek ve yaşam kalitesini artırmak amacıyla palyatif stentleme (özofagus, hava yolu veya kombine çift stent) tercih edilir. Genelde kaplı kendiliğinden genişleyen metal stentler, silikon stentlere oranla daha yüksek uyum ve daha az yer değiştirme riski nedeniyle ilk basamakta seçilir. Teknik olarak uygun ve genel durumu iyi olan iyi huylu (benign) TÖF hastalarında ise cerrahi onarım (fistülün bölünmesi, doku flebi uygulaması veya rezeksiyon) kesin ve kalıcı tedavi sağlar. Ameliyata uygun olmayan küçük benign fistüllerde klipsleme veya tıkayıcı lokal tedaviler denenebilir. Tedavi sonrasındaki 48 saat içinde sızıntı kontrolü için kontrastlı özofagram tekrarlanmalı, nüks veya stent komplikasyonları yönünden klinik takip sürdürülmelidir.
Tracheoesophageal fistula (TEF) is a pathological connection between the esophagus and the trachea, which is acquired in adults mostly due to malignant causes such as esophageal or lung cancer. Frequent coughing after solid and liquid intake, recurrent purulent bronchitis, pneumonia, and unexplained malnutrition are the most prominent clinical features prompting suspicion. Diagnosis and evaluation are established through barium contrast esophagogram, computed tomography, bronchoscopy, and endoscopy. Management requires a multidisciplinary approach involving gastroenterology, thoracic surgery, and oncology specialists. Since spontaneous closure is rare in malignant TEF, palliative stenting (esophageal, airway, or combined double stenting) is performed to alleviate symptoms, with covered self-expanding metal stents generally preferred over silicone ones due to better sealing and lower migration rates. For benign TEF cases that are technically feasible and fit for surgery, definitive surgical repair involving fistula division, tissue flaps, or resection offers a curative outcome. In patients unfit for surgery with small benign lesions, local treatments such as endoscopic over-the-scope clipping or tissue glues may be considered. Post-treatment follow-up requires a repeat contrast esophagogram within 48 hours to ensure complete sealing, alongside clinical monitoring for recurrence or stent-related complications.
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