The risk of surgical procedures for the treatment of malignant respiratory fistulas.

Abstract

The series published by Davydov and associates [1] on extended resection of esophageal carcinoma associated with fistula seems to be unique in the recent literature. Although the paper reflects the high skill and courage of the authors some theoretical and practical questions remain open. The first one is that is it justified to perform extended esophageal resection in an advanced stage of the disease when even by combined resections (lung, pericardium, diaphragm, etc.) oncologically an RO status cannot be obtained? The majority of the esophageal surgeons with waste experience (Akiyama, Skinner, Siewert, etc.) consider that esophageal carcinomas invading into the mediastinum are not suitable for resection. The effort of the authors to perform such surgery is remarkable, but the high postoperative morbidity (40%) and mortality rate (13.6%) reveal the high risk of such kind of surgery. The second one is that when the fistula is associated with airway invasion and stricture, removal of the tumor is contraindicated by technical and oncological reasons. In the by-pass group of the patients the rout, the type of the ten esophagogastric by-pass and the level of the proximal anastomosis is not clearly indicated in the text. I agree with the authors that exclusion by-pass of tracheoesophageal fistulas offer the best palliation and nutritional conditions if the patients can tolerate such type of surgery. The magnitude of this procedure is well demonstrated by the 20% postoperative mortality of this series. In our 59 malignant esophagorespiratory fistulas only one patient was in a condition permitting exclusion by-pass operation. In the other 57 cases with severely affected respiratory function and/or malnutrition by inoperable esophageal or bronchial carcinoma, fistula obliteration by esophageal intubation [2] was the unique treatment modality as in other large series [3]. In the most critical fistulas with airway invasion and stricture, as a first step we performed airway stenting, followed by esophageal intubation in ten patients. Like other authors we found that the airway stents alone cannot exclude such fistulas, so combination with esophageal tube or stent implantation [4,5] is mandatory. Using our composite cuffed funnel tube with minimal invasive insertion technique [2] the overall mortality rate was 5.4% and the postoperative morbidity only 1.8%. All our survivors had resumed on oral soft diet. In the large majority of such fistulas palliation with special esophageal tubes or esophageal and bronchial stent, may be considered a low risk, effective management.