# Diagnostic and Therapeutic Challenges of Postoperative Bronchoesophageal Fistula Leading to Acute Respiratory Distress Syndrome

## TL;DR

This paper discusses the challenges of diagnosing and treating a rare complication after esophagectomy that leads to severe lung disease.

## Contribution

The paper highlights the importance of early diagnosis and multidisciplinary management in postoperative bronchoesophageal fistula cases.

## Key findings

- Late postoperative bronchoesophageal fistula can mimic hospital-acquired pneumonia.
- Persistent air leaks and respiratory deterioration necessitate bronchoscopy for confirmation.
- ECMO and customized ventilation are critical for managing severe ARDS and supporting fistula healing.

## Abstract

Bronchoesophageal fistula (BOF) is a rare but severe complication following Ivor-Lewis esophagectomy, often leading to aspiration pneumonia and acute respiratory distress syndrome (ARDS), creating significant diagnostic and management challenges. We report a case of a man who developed BOF 26 days postoperatively, initially diagnosed as hospital-acquired pneumonia. Rapid respiratory deterioration led to intensive care unit (ICU) admission, where persistent air leaks prompted bronchoscopic confirmation of BOF. Despite endoscopic stenting and lung-protective ventilation, severe ARDS necessitated interim veno-venous extracorporeal membrane oxygenation (vv-ECMO). Unfortunately, the patient developed multiorgan failure and succumbed after 34 days on ECMO. This case underscores the importance of early diagnosis, multidisciplinary management, and balancing ventilatory strategies to support both ARDS treatment and fistula healing. BOF should be suspected in postesophagectomy patients with respiratory symptoms, even with initially negative contrast studies, and managed promptly with customized ventilation, early fistula repair, and timely ECMO support to optimize outcomes.