Airway Fistula Research Articles

P39 CHYLOPTYSIS AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER; A RARE COMPLICATION

Abstract Aim We present a case of chyloptysis after esophageal resection for esophageal squamous cell cancer. Symptoms were caused by chylous casts occluding the airways. This necessitated surgical ligation of the main thoracic duct and sealing the airway fistula with a latissimus dorsi muscle flap. Background & Methods Chyloptysis is rare and usually occurs spontaneously and secondary to disorders of the mediastinal lymphatic system. Chyloptysis manifests with the production of milky-white sputum or the formation and expectoration of bronchial casts. Initially no more than 20 cases have been reported in the literature (1,2). There are two mechanisms for the pathogenesis of chyloptysis: 1) congenital or acquired incompetence of the lymphatic valves and 2) occurrence of bronchopleural fistula in the context of chylous effusion (3,4). However, iatrogenic injury also can be a cause, in which injury to the thoracic duct leading to chylous pleural effusion with coexisting esofagotracheal fistula facilitates chyloptysis. Results A 66-year-old mal underwent a mini-invasive esophagectomy and gastric tube reconstruction for epidermoid cancer of the esophagus. Neoadjuvant chemo-radiation was given before operation. Post-operatively a minor chylous leak was managed by total parenteral nutrition for one week. He was discharged 15 days after operation. Four weeks after surgery he was readmitted because of fever, hypoxemia, wheezing, and expectoration of bronchial casts. He had fever, C-reactive protein level was 353 mg/l and white blood cell count 15.4 E9/l. He was intubated for respiratory failure and taken to ICU for treatment of aspiration pneumonia. Both chest x-ray and i.v. contrasted computed tomography (CT)of the chest confirmed bilateral aspiration pneumonia ( Figure 1). In bronchoscopy, occluding whitish mass was evacuated from both sides of the airways and this was thought to be because of aspiration (Figure 2). Infection responded to antibiotics and he was weaned from mechanic ventilation with tracheostomy until his symptoms recurred. Fiberoptic bronchoscopy revealed again milky-white sputum on both sides of the bronchial three. This time, a hole in the posterior tracheal wall was noticed and tracheal stent was applied to cover possible fistula to the esophagus or gastric conduit. However, in gastroskopy, such fistula could not be confirmed. Patient was under total parenteral nutrition (TPN) and after seven days since readmission, jejunal feeding was started. This caused a third deterioration period. Analysis of the bronchial aspiration revealed an elevated triglyceride level which was consistent with chyle and chylous fistula to the airways was therefore the most likely diagnosis. A right posterolateral thoracotomy was performed, and during surgery, thicker fibrous tissue was removed around the fistulae. Chylous reflux was observed form the fistula. Latissimus dorsi muscle flap was applied to cover the TEF and a main thoracic duct was controlled by ligating all soft tissue between descending aorta and azygous vein at the level of the diaphragm. After surgery, patient had TPN for 10 days. Enteral feeding was started to jejunal tube and we served a fat-free diet gradually increasing the fat content. Patient had tracheostomy and 2 weeks after operation he was noted to have recurrent TEF, and esophageal stent was applied. Postoperative recovery showed no further chyloptysis and he was discharged eventually 96 days after original operation. Conclusion Surgical ligation of thoracic duct resulted in complete resolution of chyloptysis. Surgery is the treatment of choice, although radiation therapy, chemotherapy, laser, and sclerosing agents have been described with varying success. To our knowledge, this is the first reported case of iatrogenic induced chyloptysis after esophageal resection.

Salvage tracheal reconstruction after failed endoscopic or surgical intervention

Tracheal reconstruction in the presence of shortened organ length and additional constraints after failed initial surgical or endoscopic intervention are rarely reported, and the conditions for success are hardly ever analyzed. Individual patients undergoing secondary tracheal reconstruction by one surgeon are described and illustrated with radiographs, endoscopic video and audio files. Four patients underwent second reconstructive tracheal attempts for postintubation injury in 2 patients, after resection of adenoid cystic carcinoma in 1 and of esophageal granular cell tumor in 1. Two patients presented with iatrogenic esophageal airway fistulas, in one following placement of a self-expanding metal stent. The surgical approach consisted of a cervical incision in 3 patients, for 1 of whom the operation was the second part of two stages, and a cervicomediastinal approach in an additional patient. The principal cause of failure was incomplete mobilization, inappropriate use of a tracheal stent, misjudgment of anastomotic tension and inappropriately radical tumor resection, respectively. After secondary reconstruction, all patients were free of airway tubes without additional recurrent laryngeal injury. First reconstructive failures before successful, second tracheal reconstruction occur because of avoidable errors in judgment or technique. First tracheal reconstructions require careful planning to reduce avoidable error. Second reconstructions may succeed when adequate residual tracheal length remains. Both demand precise surgical technique.

Use of esophageal stent for the treatment of postoperative gastrointestinal-airway fistula after esophagectomy.

A gastrointestinal-airway fistula (GAF) after esophagectomy is a very serious postoperative complication that can cause severe respiratory complications due to digestive juice inflow. Generally, GAF is managed by invasive surgical treatment; less-invasive treatment has yet to be established. We performed esophageal stent placement (ESP) in three cases of GAF after esophagectomy. We assessed the usefulness of ESP through our clinical experience. All GAFs were successfully managed by ESP procedures. After the procedure, the stent positioning and expansion were appropriately evaluated by radiological assessments over time. The stent was removed after endoscopic confirmation of fistula closure on days 8, 23, and 71. Only one patient with a long-term indwelling stent developed a manageable secondary gastrobronchial fistula as a procedure-related complication. In conclusion, ESP was shown to be a less-invasive and effective therapeutic modality for the treatment of GAF.

PS01.198: THERAPEUTIC STRATEGY FOR ONCOLOGIC EMERGENCY IN ESOPHAGEAL CANCER

Abstract Background Oncologic emergency in esophageal cancer are classified into bleeding, fistula and stenosis. The esophageal cancer infiltrating surrounding organs is inoperable. Although chemoradiotherapy is often used to cure advanced esophageal cancer with invasion to other organs, the prognosis is generally poor. In this study, we investigated and assessed the outcomes of esophageal stent, bypass surgery and salvage surgery in advanced esophageal cancer with aortic invasion, combined with aortic stent-graft. Methods 24 patients who received esophageal stent, 6 patients who received bypass surgery and 4 patients who underwent salvage surgery at the Dokkyo Medical University Hospital between April 2009 and December 2016 were reviewed retrospectively. Results The esophageal stent was performed for stenosis in 15 cases, airway fistula in 4 cases, lung fistula in 4 cases and mediastinal fistula in 1 case. Although oral intake improved in 21/24 cases (87.5%), all stenosis cases achieved to gain oral intake. On the other hand, the bypass surgery group achieved to gain oral intake in all cases. The days required to start oral intake in the stent group were significantly shorter than that of the bypass group (P < 0.05). The same results was obtained in the hospitalization (P < 0.05). In the salvage surgery group, the average operative duration was 580 min (range, 307–825 min), the average blood loss was 543ml (range, 194–914ml) and the average hospitalization was 32days (range, 15–47days). There were no postoperative complications and all cases have been achieved pathological complete response. Conclusion Even for advanced esophageal cancer needed intervention immediately, we always have investigate the curability of cancer with secured safety. Disclosure All authors have declared no conflicts of interest.

Airway Management Approach in Nasocutaneous Fistula: A Case Report.

We present a case of a 63-year-old man with nasocutaneous fistula located outside the area covered by a large adult facemask. The patient was uncooperative for the standard airway assessment and any attempt at awake intubation. Positive pressure ventilation was compromised by the fistula. Although the incidence of overall complications, including fistula formation, following free flap reconstruction for oropharyngeal cancer is reported as high as 20%, few case reports detailing airway management exist. We demonstrate that it is possible to use conventional techniques to induce and ventilate a patient with a large, externalized, airway fistula by covering the defect with an occlusive transparent dressing.

Fluoroscopy-guided removal of individualised airway-covered stents for airway fistulas

To report the techniques and complications associated with fluoroscopy-guided removal of individual covered stents for airway fistula disease over a 6-year period. A retrospective analysis was conducted of 85 patients, 72 male and 13 female, who underwent fluoroscopy-guided stent removal from January 2011 to June 2017. Patients ranged in age from 15 to 81 years (mean, 54.9±12.3 years). Before removal, 90 stents had been placed for airway fistula disease. All patients underwent diagnostic flexible bronchoscopy and airway computed tomography (CT) prior to stent removal. The indications for stent removal and post-interventional complications were analysed. Eighty-nine of 90 airway stents were successfully removed from 85 consecutive patients, for a technique success rate of 98.9%. Of these, 14 stents showed strut fracture, one stent showed retained stent pieces, and the remaining 75 stents were removed in one piece. Indications for stent removal included regular removal (n=46), stent migration (n=11), excessive granulation tissue (n=10), strut fracture (n=4), intolerance of stenting (n=6). Complications of stent removal were as follows: retained stent pieces (n=1), mucosal tear with massive bleeding (n=2), re-obstruction requiring stenting (n=1), dyspnoea with mechanical ventilation needed (n=1), and dyspnoea with oxygen inhalation needed (n=1). Airway stents can be safely removed under fluoroscopy guidance. Removal after 31-90 days is recommended for removal to avoid excessive granulation tissue.

Phase Ib/II trial of durvalumab and chemoradiation (CRT) with carboplatin/paclitaxel for esophageal and gastroesophageal junction (GEJ) adenocarcinoma.

172 Background: Pre-op CRT with carboplatin (C)/paclitaxel (P) and radiation (RT) for locally advanced esophageal cancer is a standard of care, based on the CROSS trial (NEJM 2012;366:2074). However, outcomes remain poor. Early data suggest activity of durvalumab (D) in GEJ/gastric cancer [Ann Oncol 25:iv361-372; 2014]. In a pilot study, we assessed safety of D + C/P + RT as pre-op therapy. Methods: Patients (Pts) had TanyN+ or T3-4NanyM0 esophageal and Siewert Type I/II GEJ adenocarcinoma staged by EUS, PET/CT and CT. Pts received D 1500mg x 1 dose and 4 weeks later C AUC2 and P 50mg/m2 weekly x 5 with RT (1.8Gy daily fractions to 50.4Gy). Pts also received D 1,500mg at first dose of C/P and RT. PET/CT was repeated 21-27 days post D and 4-6 weeks post CRT. Esophagectomy was planned 6-8 weeks after CRT. Pts who had R0 resections received adjuvant D 1,500mg 4 weekly x 6 doses. Initially, 6 patients were treated and followed for 30 days after surgery to assess for unacceptable toxicities. Results: 6 pts were enrolled: 3 Siewert I (50%), 2 Siewert II (33%), 1 esophageal (17%); 5 T3N1-2, 1 T4aN1. 5 pts (83%) underwent sx. 1 pt was retrospectively assessed to have metastases after induction D and taken off-study. Pathologic response was 60% in 2 pts, 90% in 1 pt, 80% in 1 pt and 40% in 1 pt; no complete response was seen. Significant grade 3/4 toxicity observed during D and CRT was neutropenia in 1 pt (17%). Adverse events (AEs) of any grade in ≥20%: lymphopenia (5 pts), thrombocytopenia (5 pts), leucopenia (4 pts), fatigue (3 pts), anemia (3 pts), neutropenia (3 pts) and abdominal pain (2 pts). Immune-related AEs were hypothyroidism (grade 2; 1 pt) and nephritis (grade 2; 1 pt). Surgical complications: 2 esophageal strictures, 1 pneumonia and 1 anastomotic leak with airway fistula, successfully treated with a stent. Immune correlative analyses from tumor blocks and whole blood are ongoing and will be reported in the poster. Conclusions: The addition of D to pre-op CRT in esophageal and GEJ adenocarcinoma appears feasible and safe. We observed no unacceptable toxicity. The study is being modified to incorporate use of induction chemo and PET (based on CALGB 80803 results) and expanded to a multicenter setting. Clinical trial information: NCT02962063.

Individualized airway-covered stent implantation therapy for thoracogastric airway fistula after esophagectomy.

Thoracogastric airway fistula (TGAF) is a rare and dangerous complication of esophagectomy performed for esophageal and cardiac carcinomas. Herein, we aimed to explore the feasibility and efficacy of individualized airway stent implantation for the treatment of TGAF after esophagectomy. Based on different TGAF types and relevant data on chest computed tomography, customized airway-covered stents were positioned so as to cover the entrance to the fistula by an interventional radiologist using fluoroscopic guidance. Of the 63 patients with TGAF, 12 had thoracogastric-tracheal fistulas, 14 had thoracogastric-carinal fistulas, 21 had thoracogastric-left main bronchial fistulas, 15 had thoracogastric-right main bronchial fistulas, and 1 had a thoracogastric-right intermediate bronchial fistula. The following different stent types were placed: 7 straight self-expandable covered metallic stents, 2 hinged self-expandable covered metallic stents, 41 Y-shaped self-expandable covered metallic stents, and 13 large Y and small Y paired self-expandable covered metallic stents. In all 59 cases (93.65%), the implantation was successful at the first attempt, with the procedure times ranging from 5 to 10min. Esophagograms with water-soluble iodinated contrast showed that the fistulae were completely covered with no contrast flowing into the airways and lungs, and with the stents fully expanded. We recorded four cases (6.35%) of incomplete or recurrent fistula closure. Customized airway-covered stents may be an appropriate palliative therapy for patients with thoracogastric airway fistula who are unfit for surgery or have a high postoperative risk.

Robotic-Assisted Oesophageal Surgery

Abdominothoracic oesophageal resections, also known as Ivor Lewis procedures, are complex visceral surgery procedures. In recent years, substeps have increasingly been performed using minimally invasive techniques. However, intrathoracic anastomosis is still a challenge given the instrumental and technological possibilities available to date. This article provides a detailed description of the use of the Da Vinci robotic system and our techniques in oesophageal surgery. In a prospective data collection, we analysed the robotic-assisted oesophageal surgeries performed at the University Hospital of Schleswig-Holstein, Campus Kiel, between November 2013 and November 2015. A total of 56 patients underwent robotic-assisted oesophageal surgery, with 43 patients undergoing the Ivor Lewis technique, 10 patients undergoing the McKeown procedure and 3 patients undergoing enucleation of a leiomyoma. A complete tumour resection (R0 margin) was achieved in 53 patients (93.4%); the mean number of resected lymph nodes was 23 (14-75). Forty-five (80.5%) patients received an induction therapy. Mean operative time was 412 min (120-610); mean hospital stay was 19 days (4-145). A conversion to open surgery was necessary in 19 (34.1%) cases, most notably in the thoracic part of the surgical procedure (17 patients). Forty-three patients received intrathoracic oesophagogastrostomy; 4 out of 5 patients with an initial side-to-side anastomosis developed a leakage, whereupon the technique was switched to a hand-sewn procedure (leakage in 3 out of 20 patients). Other major morbidities included leakage of the gastric conduit in 2 patients (3.6%), airway fistula in 2 patients (3.6%), mesenteric ischaemia in one patient (1.8%), and peritonitis due to a dislocated feeding tube in one other patient. Pulmonary complications occurred in 19 patients (34%). Four patients (7.1%) died of pulmonary embolism, heart attack, and septic organ failure. Robotic-assisted, minimally invasive oesophagectomy is a feasible and useful approach for oncological surgery. This technique should be implemented in a structured program with an extensive and critical evaluation of the users' own results and an exchange with other experienced work teams. This helps to avoid pitfalls and to speed up the learning curve. Further technological developments and increasing experience might lead to a more widespread use of this technique.

Managing complications II: conduit failure and conduit airway fistulas.

Conduit failure and conduit airway fistula are rare complications after esophagectomy, however they can be catastrophic resulting in high mortality. Survivors can expect a prolonged hospital course with multiple interventions and an extended period of time prior to being able to resume oral nutrition. High index of suspicion can aid in early diagnosis. Conduit failure usually requires a period of proximal esophageal diversion and staged reconstruction. Conduit airway fistulas may be amenable to endoscopic repair but this has a high failure rate and many patients will require surgical repair with closure of the fistula and interposition of vascularized tissue to minimize recurrence.

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.

Clinical application of a fully covered self-expandable metallic stent in treatment of airway fistula

To assess the feasibility, safety and efficacy of the use of a fully covered self-expandable stent for the treatment of airway fistula. From August 2005 to November 2011, 9 patients underwent treatment by the introduction of a tracheo-bronchial or bronchial fully covered self-expandable metallic stent. There were 7 males and 2 females, aged from 28-65 years with a mean of 46 years. In this group, 7 cases were diagnosed as bronchopleural fistula, 1 case as tracheopleural fistula, 1 case as broncho-esophageal fistula, 8 cases with thoracic empyema. The fistula orifices were from 3.5-25.0 mm in diameter with a mean 8.4 mm. All patients received topical anesthesia, and L-shaped stent was placed in 6 patients and I-shaped stent in 3 patients under fluoroscopic guidance. After the stent placement, the patients with empyema were treated with continual irrigation of the empyema cavity. Stent placement in the tracheo-bronchial tree was technically successful in all patients, without procedure-related complications. The operating time was from 5-16 minutes, mean time (10 ± 4) minutes. Except for 1 patient, immediate closure of the airway fistula was achieved in the other patients after the procedure, as shown by the immediate cessation of bubbling in the chest drain system or the contrast examination. In this study, 1 patient coughed the inserted stent out due to irritable cough on the 5th day and had to receive repositioning of a new stent. Among the patients who were with empyema, 1 patient died of septicemia on the 8th day and 1 patient died of brain metastases from lung cancer 6 months after the stent insertion with empyema not cured, the other 6 patients' empyema healed from 2-5 months, mean time 3.7 months. Seven patients were followed from 3 to 36 months with a median of 13.5 months. During follow-up, 1 stent was removed from a patient 8 months after the stent implantation without empyema recurred. The remaining patient presented good tolerability to the existence of stent. The stents remained stable, no migration occurred, no empyema recurred, and the patient with broncho-esophageal fistula fed and drunk well. The use of fully covered self-expandable stents proved to be a safe, effective and fast minimally invasive method to treat airway fistula, especially for patients with a higher surgical risk or other failed treatments.

The Utility of Stenting in the Treatment of Airway Gastric Fistula After Esophagectomy for Esophageal Cancer

The purpose of this study was to determine the overall efficacy of airway stenting in the treatment of patients developing airway gastric fistula (AGF) after esophagectomy. MEDLINE/PubMed search from January 1990 to November 2011 was conducted using the search terms "esophageal cancer," "esophagectomy," "airway fistula," "tracheal fistula," "bronchial fistula," and "stent" alone and in combination. The authors identified 2 case series and 8 case reports. All case series and reports were reviewed to include the number of patients, the type of stent utilized, the location of AGF (tracheal or bronchial), the overall success in closure, recurrence (to include time to recurrence), and outcome if available. The Mantel-Haenszel analysis was performed on the basis of the type of stent and location of the AGF as it related to efficacy and outcome. AGF after esophagectomy for esophageal cancer is rare. Although surgical repair offers definitive treatment, the operative risk in such patients is high. With a nonsurgical approach, an analysis of available case reports/series suggests a trend toward more durable closure of AGF with the utilization of covered metallic stents and when the fistula is bronchial in origin. Despite a high recurrence rate (39%), stenting may provide temporization until surgery can be tolerated. Airway stenting for AGF should not be considered as a definitive therapy and when utilized it requires frequent reassessment for recurrence.

Sealing of airway fistulas for metallic covered z-type stents

背景与目的气道瘘包括食管气管瘘、支气管胸膜瘘和气管纵隔瘘，临床治疗较为棘手。本文旨在探讨被膜金属支架封堵气道瘘的疗效和安全性。方法回顾性分析32例食管气管瘘、5例支气管胸膜瘘和1例气管纵隔瘘患者在气管镜和/或X线透视下放置被膜金属支架。原发病为食管肿瘤26例，肺癌11例，甲状腺癌1例。结果38例患者共有46个瘘口，口径0.5 cm-7.0 cm。放置Z型气管被膜金属支架40枚(其中Y形24枚，L形8枚和I形8枚)。食管放置被膜金属支架24枚。46个瘘口封堵疗效：治愈2例(4.3%)，临床完全缓解28例(60.9%)，部分缓解11例(23.9%)，无效5例(10.9%)，有效率为89.1%，中位生存时间为5个月。结论被膜金属支架能有效封堵食管气管瘘、支气管胸膜瘘和气管纵隔瘘。应首选气管支架封堵ERF，无效的患者可同时放置食管支架。分叉型气管支架尤其适于隆突周围瘘口。

Clinical benefits and complications of Dumon stent insertion for the treatment of severe central airway stenosis or airway fistula

The purpose of this study was to evaluate the clinical benefits and complications of Dumon stent insertion for patients with central airway disorders including stenosis and fistula. This was a retrospective analysis of medical records regarding alleviation of symptoms, occurrence of complications, and technical problems. Since August 1998, the Dumon stent has been used in 35 consecutive patients, included 24 with malignant airway stenosis, 5 with benign stenosis, and 6 with airway fistula. Altogether, 7 patients had a straight stent inserted into the trachea, 17 had a Y-stent inserted into the carina, and 11 patients had a straight stent inserted into the bronchus. In 33 of the 35 patients, the symptoms dramatically diminished after stent insertion. Poststenting complications included increased coughing in 37% of the patients, an obstruction of the stent due to secretion in 8.6%, migration in 5.7%, granulation in 2.9%, and cerebral infarction in 2.9%. Ten patients had the stent removed for various reasons, and five of the ten underwent reinsertion of a new stent. Migration could be avoided by external fixation with nylon threads in the upper trachea. Three of six patients with an airway fistula showed resolution of the fistula, and the remaining three patients improved symptomatically. Five of these six patients had undergone radiotherapy prior to stent insertion. The Dumon stent was found to be effective for treating not only airway stenosis but also airway fistula, with permissible complications. The Dumon stent is therefore considered to be the most effective airway stent presently available worldwide based on both cost and safety factors.

INVITED COMMENTARY

Technologic advances have facilitated the management of many postsurgical complications. When applied to the correct patient, at the appropriate time, these techniques can facilitate recovery of the patient and avoid the morbidity and possible mortality associated with an operative reintervention, often in a critically ill patient. Crucial to the success of these endeavors is early intervention when a complication develops, and also the ability to recognize the failure of nonoperative intervention early enough in the course to resort to an alternate plan to salvage the situation. Langer and colleagues report on the use of stents to manage esophageal anastomotic leaks, both cervical and intrathoracic. Despite many modifications, this complication still occurs in 10% to 33% of resections. The authors utilized the Polyflex stent (Willy Ruesch GMBH, Kernan, Germany) to endoscopically manage this vexing, and potentially lethal complication. The goals of stenting appeared twofold; one to prevent death from continued soiling of the mediastinum, and one for the cervical anastomoses, prevention of the strictures often associated with a cervical leak. This report clearly describes the good, the bad, and the ugly associated with this technique. The good is those patients whose leaks were successfully managed nonoperatively. Their leaks were sealed and no further operative intervention was required. The bad were the patients who succumbed despite having been stented, leaving one to question the timeliness and adequacy of the intervention. Would takedown of the anastomosis and/or diversion been the optimum choice? The ugly may be seen in an early and a late phase. The early phase occurring in the patients whose anastomoses were further disrupted by stent placement, thus requiring an emergent operation to achieve any chance of survival. The late phase we can foresee in the group of patients left with those “benign” stents in place. Gaissert and colleagues [1Gaissert H.A. Grillo H.C. Wright C.D. et al.Complications of benign tracheobronchial strictures by self-expanding metal stents.J Thorac Cardiovasc Surg. 2003; 126: 744-747Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar] have recently described the problems resulting from the placement of stents in the airway in lieu of definitive surgical repair. One has to be concerned regarding the development of vascular and airway fistulas in the patients left stented indefinitely. Stenosis of the esophagus proximal to these stents will not leave us much room to work, and result in a miserable existence for the patient. As esophageal surgeons we should keep an open mind to the use of these devices in the management of our postoperative complications, but not be lulled into a false sense of security that a nonoperative approach is always better than a well done operation. Management of Postoperative Esophageal Leaks With the Polyflex Self-Expanding Covered Plastic StentThe Annals of Thoracic SurgeryVol. 79Issue 2PreviewEsophageal anastomotic leaks can lead to prolonged hospitalization. In this article we present our experience with the placement of the Polyflex self-expanding plastic stent (Willy Ruesch GMBH, Kernen, Germany) for leak occlusion. Full-Text PDF

New frontiers in CT imaging of airway disease.

Combining helical volumetric CT acquisition and thin-slice thickness during breath hold provides an accurate assessment of both focal and diffuse airway diseases. With multiple detector rows, compared with single-slice helical CT, multislice CT can cover a greater volume, during a simple breath hold, and with better longitudinal and in-plane spatial resolution and improved temporal resolution. The result in data set allows the generation of superior multiplanar and 3D images of the airways, including those obtained from techniques developed specifically for airway imaging, such as virtual bronchography and virtual bronchoscopy. Complementary CT evaluation at suspended or continuous full expiration is mandatory to detect air trapping that is a key finding for depicting an obstruction on the small airways. Indications for CT evaluation of the airways include: (a) detection of endobronchial lesions in patients with an unexplained hemoptysis; (b) evaluation of extent of tracheobronchial stenosis for planning treatment and follow-up; (c) detection of congenital airway anomalies revealed by hemoptysis or recurrent infection; (d) detection of postinfectious or postoperative airway fistula or dehiscence; and (e) diagnosis and assessment of extent of bronchiectasis and small airway disease. Improvement in image analysis technique and the use of spirometrically control of lung volume acquisition have made possible accurate and reproducible quantitative assessment of airway wall and lumen areas and lung density. This contributes to better insights in physiopathology of obstructive lung disease, particularly in chronic obstructive pulmonary disease and asthma.

Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula

Background: Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications. Methods: All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival. Results: Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (±SD) improved from 2.6 (0.7) to 1.1 (1.2) ( p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent). Conclusions: The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed. (Gastrointest Endosc 1996;44:562-7.)

Esophageal cancer with airway fistula: Palliative treatment by placement of a tracheobronchial stent: [formula omitted], M. Giovannini, B. Seitz, J.F. Seitz. Service d'Oncologie Digestive, Institut Paoli-Calmettes, Marseille, France

Esophageal cancer with airway fistula: Palliative treatment by placement of a tracheobronchial stent: [formula omitted], M. Giovannini, B. Seitz, J.F. Seitz. Service d'Oncologie Digestive, Institut Paoli-Calmettes, Marseille, France

Microvascular Free Muscle Flaps for Chronic Empyema with Bronchopleural Fistula When the Major Local Muscles Have Been Divided—One-stage Operation with Primary Wound Closure

It should be emphasized that most cases of chest empyema can be successfully treated with conventional thoracic surgery procedures. For chronic empyema with a bronchopleural fistula complicated by previous division of major local muscles following repeated thoracotomies, free muscle flaps are employed. Five such cases treated with this method resulted in successful closure of the airway fistula, as well as complete obliteration of the empyema cavity in a single operation. This method is very effective in eradicating infection and achieves prompt wound healing, decreased morbidity, and gradual improvement of pulmonary function after surgery. Analysis of roentgen ray and computed tomographic scans before and after surgery shows lung expansion when the transferred muscles atrophy. The results are satisfactory. The method described here is not the only solution to this problem, but it is a new approach that has advantages not seen in conventional methods. It is indicated only in patients who have been operated on many times and who have no remaining available local muscles.