Aerodigestive Fistula Research Articles

Management and outcomes in a consecutive series of patients with aero-digestive fistula at a tertiary gastro-esophageal surgery center.

Aerodigestive fistula (ADF) is defined as a pathological connection between the upper digestive tract and the airway. ADF is associated with high morbidity and mortality and management is often complex. A cohort study including all patients admitted with ADF 2004-2022 at a single tertiary esophageal surgery center was performed based on prospectively collected administrative data and retrospectively collected electronic patient chart data,. Patient demographics, performance status, comorbidity, fistula characteristics, management, and outcomes in terms of morbidity and mortality were assessed in patients with ADF of three distinct types: (i) tumor overgrowth-related, (ii) various benign etiologies, and (iii) post-esophagectomy. Sixty-one patients with ADF were included in the study, 33 (54.1%) tumor overgrowth-related, six (9.8%) benign and 22 (36.1%) post-esophagectomy. In the post-esophagectomy group 15 out of 22 (68.2%) patients were diagnosed with anastomotic leakage prior to ADF diagnosis. Self-expandable metallic stents (SEMS) were used for temporary fistula sealing in 59 out of 61 (96.7%) patients, of which most received stents in both the digestive tract and airway. Temporary fistula sealing with stents was successful enabling discharge from hospital in 47 out of 59 (79.7%) patients. Definitive ADF repair was performed in 16 (26.2%) patients, of which one (6.3%) died within 90-days and 15 could be discharged home with permanently sealed fistulas. ADF is a complex condition associated with high mortality, which often requires multiple advanced interventions. SEMS can be applied in the airway and simultaneously in the digestive tract to temporarily seal the ADF as bridge to definitive surgical repair.

Tracheal Y-Stent-induced Carinal Reunion after Complicated Aerodigestive Fistula.

"Tracheal Y-Stent–induced Carinal Reunion after Complicated Aerodigestive Fistula." American Journal of Respiratory and Critical Care Medicine, 207(5), pp. 613–614

Flexible Bronchoscopy Diagnosis of Uncommon Congenital H-type Tracheoesophageal Fistula, Dual Fistulae, Bronchoesophageal Fistula, and Recurrence of Fistula in Children: A 20-year Experience.

Interventional pediatric flexible bronchoscopy has many advantages over radiologic investigations in diagnosing uncommon congenital H-type tracheoesophageal fistula (TEF), dual TEF, bronchoesophageal fistula (BEF) and fistula recurrence including higher rates of identification and anatomic localization with guide wire cannulation. We compare the diagnostic utility of flexible bronchoscopy to radiologic techniques for congenital aerodigestive fistula. A single center retrospective review was completed of all cases of pediatric TEF and BEF diagnosed with flexible bronchoscopy between January 2000 and November 2020. Fistulae were diagnosed 21 times in 18 patients at a median age of 1.22 years (interquartile range: 0.50 to 2.99). The median time from diagnosis to repair was 17.5 days (interquartile range: 5.5 to 43). Symptoms commonly related to fistula were found in all patients. Uncommon fistulae included single H-type TEF (n=10, 47.6%), dual H-type TEF (n=2, 9.5%), dual proximal and distal TEF with esophageal atresia (n=5, 23.8%), TEF recurrence (n=2, 14.3%), BEF (n=1, 4.8%), and a BEF recurrence (n=1, 4.8%). Flexible bronchoscopy confirmed the diagnosis in all fistulae using a guide wire cannulation or methylene blue dye injection. A combined procedure with simultaneous bronchoscopy and esophagoscopy was used for 6 fistulae. The positive examination rate was 75% for bronchoscopy compared with 2.6% for contrast swallow studies and 28.6% for tube esophagograms. Flexible bronchoscopy should be considered as a first line investigation in uncommon aerodigestive fistulae. In the absence of a skilled bronchoscopist, the best radiologic investigation is a pull-back tube esophagogram but may still require endoscopic confirmation at the time of fistula repair.

Treatment of aerodigestive fistulas with a novel covered metallic Y-shaped segmented airway stent customized with the assistance of 3D printing.

BackgroundThe management of aerodigestive fistula remains challenging. An airway stent that matches well with the individual geometry of the airway is needed for the treatment of the aerodigestive fistula. This study aimed to evaluate the feasibility of a novel covered metallic segmented Y-shaped airway stent customized with the assistance of 3D printing in aerodigestive fistulas involving the carina and distal bronchi and to compare the flexibility of the novel stent with the conventional wholly knitted stent.MethodsIn the flexibility study, we measured the longitudinal bending force and spring-back force of the segmented stent and wholly knitted stent. Patient-specific stents that were individually customized with the assistance of 3D printing technology were implanted in 26 patients with aerodigestive fistulas. The technical success, clinical success, Karnofsky performance status (KPS), and stent-related complications were recorded.ResultsThe bending force and spring-back force of the segmented stent were significantly lower than those of the wholly knitted stent. Stent deployment was technically successful in all patients. Clinical success was obtained in 21 patients. The KPS of patients after the stenting procedure improved significantly compared with that before stenting (P<0.001). During follow-up, granulation tissue proliferation, sputum retention, stent migration, and intolerance of the stent were found in 2, 5, 1, and 1 patient, respectively.ConclusionsThe segmented metallic Y-shaped airway stent had greater flexibility than the wholly knitted stent in an ex vivo setting. Implantation of the segmented stent individually customized with the aid of 3D printing is feasible in treating aerodigestive fistulas involving the carina and bronchi distal to the carina.

The surgical management of non-malignant aerodigestive fistula

BackgroundAcquired aerodigestive fistula (ADF) are rare, but associated with significant morbidity. Surgery affords the best prospect of cure. We present our experience of the surgical management of ADFs at a specialist unit, highlighting operative techniques, challenges and assess clinical outcomes following intervention. We also illustrate findings of a Hospital Episodes Statistics search for ADFs.MethodsA prospectively-maintained database was searched to identify all patients diagnosed with an ADF who were managed at our institution. Of 48 patients with an ADF, eight underwent surgical intervention.ResultsFour patients underwent an exploration of the ADF with primary repair of the defect. Two of these patients had proximal ADFs, amenable to repair through a neck incision, and two required a thoracotomy. Two patients suffered fistulae secondary to endoscopic therapy and underwent oesophageal exclusion surgery, with subsequent staged reconstruction. Two patients with previous Tuberculosis had a lung segmentectomy and lobectomy respectively, and a further patient in remission after treatment for lymphoma underwent oesophageal resection with synchronous reconstruction. Three patients suffered a complication, with one post-operative mortality. The remaining seven patients all achieved normal oral alimentation, with no evidence of ADF recurrence at a median follow-up of 32 months.ConclusionsSurgery to manage ADFs is effective in restoring normal alimentation and alleviates soiling of the airway, with a very low risk of recurrence. Several operative techniques can be utilised dependent on the features of the ADF. Early referral to specialist units is advocated, where the expertise to facilitate the complete management of patients is present, within a multi-disciplinary setting.

Bronchoscopic advances in the management of aerodigestive fistulas

Malignant aerodigestive fistula (ADF) is an uncommon condition complicating thoracic malignancies. It results in increased morbidity and mortality and warrants therapeutic intervention. The management approach depends on symptoms, configuration, location, and extent of the fistula. This article will discuss the therapeutic considerations in the management of ADF.

Acquired Adult Aerodigestive Fistula: Classification and Management

BackgroundAcquired aerodigestive fistulae (ADF) are rare, but associated with a high mortality rate. We present our experience of the diagnosis, management and outcomes of patients with ADFs treated at a tertiary centre. Utilising our findings, we propose an anatomical classification system, demonstrating how specific features of an ADF may determine management. MethodsA clinical database was searched and 48 patients with an ADF were identified. A classification system was developed based on anatomical location of the ADF and differences in clinico-pathological features based on this categorisation were performed, with the chi-squared test used for inferential analyses and Kaplan-Meier curves with log-rank test to assess survival. ResultsTwenty (41.6%) patients developed an ADF secondary to malignancy, with previous radiotherapy (18.7%), post-operative anastomotic dehiscence and endotherapy (14.6% each) representing other causes. Thirty-one patients were managed with tracheal and/or oesophageal stents and eight underwent surgical repair. The classification system demonstrated benign causes of ADF were either proximally or distally sited, whilst a malignant cause resulted in mid-tracheal fistulae (p=0.001), with the latter associated with poorer survival. ADFs over 20 mm in size were associated with poor survival (p=0.011), as was the use of previous radiotherapy. Proximal and distal ADFs were associated with improved survival (p=0.006), as were those patients managed surgically (p=0.001). ConclusionBy classifying ADFs, we have demonstrated that anatomical location correlates with the size, history of malignancy, previous radiotherapy and aetiology of ADF, which can affect management. The proposed classification system will aid in formulating multi-modality individualised treatment plans.

Respiratory-digestive tract fistula: two-center retrospective observational study.

Background Aerodigestive fistulae can be defined as abnormal communications between the gastrointestinal tract and the respiratory tract. Choking after meals, coughing, feeding difficulties, tachycardia, and persistent pneumonia are the main presentations. The aim of our study was to review our experience in the management of 27 cases of acquired aerodigestive fistulae of different types, levels, and management. Methods We conducted a retrospective observational study on 27 cases of fistulae between the respiratory and digestive tracts, which were managed in 2 hospitals in Saudi Arabia in the last 5 years. The patients comprised 16 females and 11 males, with a mean age of 29 years (range 17-67 years). Results The most common aerodigestive tract fistula was tracheoesophageal in 8 patients, followed by esophagobronchial in 6, and esophagopleural in 5. Four postendoscopic fistulae were included. The least common were gastropleural and esophagopulmonary fistulae. The most common etiologies were iatrogenic and esophageal cancer, and the least common was blunt chest trauma. The main presentations were fever, chocking after or during meals, and tachycardia. We used various modalities of treatment: conservative, cervical repair, thoracoabdominal repair, hybrid insertion of a T-tube, endoscopic esophageal stenting, and endoscopic clipping of the fistulous tract. During follow-up, 6 patients died due to advanced esophageal cancer in 5 and upper airway obstruction after iatrogenic tracheobronchial fistula in one. Conclusion Acquired aerodigestive fistula is a devastating condition that should be managed early and aggressively by a multidisciplinary team.

Aerodigestive Fistula Formation as a Rare Side Effect of Antiangiogenic Tyrosine Kinase Inhibitor Therapy for Thyroid Cancer

In the past decade, targeted therapy with antiangiogenic drugs has become standard of care for most types of metastatic, progressive thyroid cancer. While these drugs were thought initially to be less toxic than traditional chemotherapy, they can have rare but serious and fatal toxicities. Once such toxicity that has been reported in other tumor types is upper airway fistula formation, which can be life-threatening. Here, we describe three patients treated with antiangiogenic tyrosine kinase inhibitors at two academic institutions who developed aerodigestive fistula. All three patients had risk factors for fistula formation, which included external beam radiation and/or large tumor with invasion of the tracheal wall. Fistula formation is a known but rare side effect of antiangiogenic tyrosine kinase inhibitors. Knowledge of the risk factors that may predispose thyroid cancer patients to this serious adverse event is vital prior to prescribing antiangiogenics. Particular caution should be observed when using these drugs in patients undergoing radiation therapy or surgery, or in patients whose tumor is invading vital structures of the neck, as they may be at higher risk of developing this rare complication. In these patients, antiangiogenic tyrosine kinase inhibitors should be used cautiously, patients should be aware of the risk, and physicians should monitor patients for symptoms of fistula.

DIFFICULT TO MANAGE BRONCHOGASTRIC FISTULA PALLIATED WITH DJ (DIAZ-JIMENEZ) FISTULA PROSTHESIS AND TRACHEAL Y-STENT

INTRODUCTION: Aerodigestive fistula is a dreaded complication after treatment of esophageal carcinoma. The primary management method for patients with malignant disease is stenting in esophageus, airway or both. When technically feasible, surgery is the preferred treatment for benign disease. Herein, we report a case of bronchogastric fistula, occurring after esophagogastrectomy, managed with a combination of methods.

Palliation of malignant aerodigestive fistulae with self-expanding metallic stents

Malignant aerodigestive fistulae are rare but devastating sequelae of thoracic cancers, most commonly associated with esophageal cancer. Survival following development of a malignant aerodigestive fistula is measured in weeks. Palliation is the primary goal of therapy and to this end, we report the use of self-expanding metallic stents (SEMS) as treatment. Between May 1999 and January 2004, 12 patients were treated for malignant aerodigestive fistulae. The underlying diagnosis was esophageal cancer for 10 patients, and non-small cell lung cancer for two others. All patients were symptomatic and fistulae were diagnosed by esophagoscopy in seven, bronchoscopy in two, and esophagram in three. Seven covered Wallstents (seven esophageal) and eight covered Ultraflex (five tracheal and three esophageal) were used. A single stent was placed in eight patients (seven esophageal and one tracheal). Three patients required esophageal and tracheal stents and one patient needed two tracheal stents. General anesthesia was required in 50% of the patients. There were no procedure-related complications. Symptoms were palliated in 100% of patients and oral intake was reinstituted in 42% (5/12). All the patients were discharged from hospital after SEMS placement and one patient returned for an uneventful tracheal stent replacement secondary to mucus impaction 2 months later. SEMS placement is an effective strategy to palliate malignant aerodigestive fistulae. Complications are rare and symptoms are alleviated in most patients.