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

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.