Bronchoesophageal Fistula Research Articles

Unusual Surgical Repair of Bronchoesophageal Fistula Following Esophagectomy.

Radical esophagectomy remains the only potentially curative option in the treatment of esophageal cancer. However, this procedure is burdened with high morbidity and mortality rates, even in high-volume centers. A tracheo- or bronchoesophageal fistula (TBF) is rare but is one of the most difficult life-threatening complications following an esophagectomy for cancer treatment. Several classifications have been proposed regarding the localization of a TBF, its etiology, and the timing of its occurrence; hence, no classification is universally accepted. However, one of the most common etiological explanations for the formation of a TBF is a prior esophagogastric anastomotic leak. Treatment options include a conservative approach, which usually combines several endoscopic methods. Surgical treatment is directed towards fistula closure with direct suturing or, more often, the usage of pediculated flaps. Here, we present a patient with late TBF following a minimally invasive esophagectomy, which was surgically solved in an atypical way. We believe that this type of repair may be useful in patients in whom pedunculated flaps are not an option.

Použitie Watanabeho spigotov v manažmente bronchoezofageálnych fi stúl

Summary: Bronchoesophageal and bronchogastric fistulas are rare complications of thoracic surgery as esophagectomy, malignancy or prolonged endotracheal intubation. Although uncommon, their morbidity and mortality is substantial. Treatment of these fi stulas is challenging and often lengthy with limited success rates. Endoscopic treatment may be the treatment of choice for some types of fi stulas, but despite a variety of methods available, the success rate is relatively low with little consistent data about its eff ectiveness. At the same time, new technologies and devices have become available with a potential to address these complicated conditions. One of them are Watanabe spigots, initially used in pneumology for the treatment of persistent pneumothorax and pyothorax with bronchial fi stula. In the presented case reports Watanabe spigots are used in combination with over-the-scope clips in two of our patients with bronchoesophageal fi stulas fol lowing esophagectomy with promising results. We also present an overview of endoscopic methods of therapy in the context of and separately discuss available evidence about the possibilities of the use of Watanabeho spigots in the treatment of bronchoesophageal fi stulas. Key words: bronchoesophageal fi stula – Watanabe spigot – esophagectomy – over-the-scope clip

X-ray-guided self-expandable metal stent (SEMS) implantation in oesophageal malignancy as an alternative treatment.

<b><br>Indroduction:</b> Significant dysphagia, aspiration pneumonia, and impossible oral nutrition in patients with unresectable or recurrent gastroesophageal malignancy or bronchial cancer invading the oesophagus with a tracheoesophageal fistula lead to cachexia. Dehiscence of the esophago-jejunal or gastroesophageal anastomosis may cause severe oesophageal haemorrhage. We believe that X-ray-guided oesophageal stent implantation (SEMS) is an alternative palliative method for microjejunostomy or full parenteral nutrition.</br> <b><br>Aim:</b> The aim of this paper was to assess the safety and efficacy of a novel X-ray-guided oesophageal stent implantation technique.</br> <b><br>Materials and methods:</b> This retrospective analysis included 54 patients (35 men and 19 women) treated for malignant dysphagia, gastroesophageal/gastrointestinal anastomotic fistula or bronchoesophageal fistula in two Surgical Units between 2010 and 2019, using a modified intravascular approach to oesophageal stent implantation.</br> <b><br>Results:</b> The presented modified intravascular method of oesophageal stent implantation was successfully performed in all described patients requiring oral nutrition restoration immediately following oesophageal stent implantation. Two patients with oesophageal anastomotic dehiscence died on postoperative days 7 and 9 due to circulatory and respiratory failure. One patient was reimplanted due to a recurrent fistula. Two patients with ruptured thoracic aneurysm and thoracic stent graft implantation due to oesophageal haemorrhage, who were implanted with an oesophageal stent, died on postoperative days 4 and 14.</br> <b><br>Conclusions:</b> The modified intravascular X-ray-guided SEMS technique may be a palliative treatment for patients with unresectable oesophageal malignancies.</br&gt.

Tracheal agenesis versus tracheal atresia: anatomical conditions, pathomechanisms and causes with a possible link to a novel MAPK11 variant in one case

BackgroundIn this study we aimed to describe the morphological and pathogenetic differences between tracheal agenesis and tracheal atresia, which are not clearly distinguished from each other in the literature, and to contribute thereby to the understanding and management of these conditions. Both tracheal agenesis and tracheal atresia represent rare disorders of still unknown aetiology that cannot be detected by prenatal ultrasound. If the affected foetuses survive until birth these conditions result in respiratory failure and in futile attempts to rescue the infant’s life.ResultsAutopsies and genetic analyses, including singleton or trio exome sequencing, were performed on five neonates/foetuses with tracheal agenesis and three foetuses with tracheal atresia. Tracheal agenesis was characterized by absence of the sublaryngeal trachea and presence of a bronchooesophageal fistula and by pulmonary isomerism and occurred as an isolated malformation complex or as part of a VACTERL association. Special findings were an additional so-called ‘pig bronchus’ and a first case of tracheal agenesis with sirenomelia. Tracheal atresia presenting with partial obliteration of its lumen and persistence of a fibromuscular streak resulted in CHAOS. This condition was associated with normal lung lobulation and single, non-VACTERL type malformations. Trio ES revealed a novel variant of MAPK11 in one tracheal agenesis case. Its involvement in tracheooesophageal malformation is herein discussed, but remains hypothetical.ConclusionTracheal agenesis and tracheal atresia represent different disease entities in terms of morphology, pathogenesis and accompanying anomalies due to a primary developmental and secondary disruptive possibly vascular disturbance, respectively.

MSCT study for adult esophageal diverticulum with secondary broncho-esophageal fistula

BackgroundBroncho-esophageal fistula (BEF) secondary to esophageal diverticulum is a rare clinical condition, which is often misdiagnosed for a long time. The aim of our study is to summarize and clarify the advantages of MSCT in diagnosing BEF secondary to esophageal diverticulum.MethodsWe retrospectively analyzed patients clinically diagnosed with BEF from January 2005 to January 2022 at Jilin University First Hospital. Only those patients with BEF secondary to esophageal diverticulum and complete clinical data met our enrolled standard. All patients’ clinicopathologic characteristics and MSCT features were systemically evaluated.Results17 patients were eligible for our cohort study, including male 10 and female 7. The patient’s mean age was 42.3 ± 12.5. The chronic cough occurred in all seventeen patients and bucking following oral fluid intake was documented in nine patients. MSCT distinctly suggested the fistulous tract between the bronchi and the esophagus in all patients. The mean diameter of the orifices in the wall of the esophagus was 4.40 ± 1.81 mm. The orifice in the midthoracic esophagus side was 15 cases and 2 cases at the lower thoracic esophagus. The involved bronchus included 13 cases at the right lower lobe bronchus, 1 at the right middle lobe bronchus and 3 at the left lower lobe bronchus. The contrast agent was observed in the pulmonary parenchyma in 10 of 13 patients who underwent esophagogram. No definite fistula was observed in 3 of 11 who underwent gastroscopy, while the intra-operative findings supported the existence of fistula.ConclusionsBEF secondary to esophageal diverticulum tends to occur between the midthoracic esophagus and the right lower lobe bronchus. Compared with esophagography and gastroscopy, MSCT shows more comprehensive information about the fistulous shape, size, course and lung involvement, which are helpful for establishing diagnosis and guiding subsequent treatment.

Broncho-esophageal fistula: When surgery and endoscopy fail, consider physiological lung exclusion

We discuss the case of an esophageal cancer patient treated by chemo and radiotherapy complicated by an esophageal stenosis and an iatrogenic broncho-esophageal fistula. This latter was managed with multiple palliative stenting procedures and colonic surgical bypass. Despite a long disease free survival but decreased quality of life and frailty, we came to the proposal of an extremely unusual form of treatment - physiological lung exclusion, with clinical benefit and so far without any drawbacks related to the procedure.

The final plug: novel use of vascular plug for management of bronchoesophageal fistula

Video 1Successful management of a postsurgical bronchoesophageal fistula with a combination of a self-expanding vascular plug, glue containing cyanoacrylate, and a fully covered metal stent.

Preliminary results in tracheal replacement using stented aortic matrices for primary extensive tracheal cancer.

Recent studies have demonstrated the feasibility and favorable long-term results of tracheobronchial replacement using stented cryopreserved aortic allografts. We propose to investigate the outcomes of this emerging technique in the subgroup of patients with extensive tracheal cancer. This study was based on 13 patients with primary extensive tracheal cancer extracted from the prospective registry TRITON-01 (ClinicalTrials.gov Identifier: NCT04263129), which included 40 patients in total. We analyzed early and late outcomes in this subset of patients. From March 2019 to September 2022, 13 patients were included in the study. There were 9 female and 4 male patients, with a mean age of 53.9years [36-71 years]. They had tracheal replacement for extended adenoid cystic carcinoma (n=11), squamous cell carcinoma (n=1), and mucoepidermoid carcinoma (n=1). A venovenous extracorporeal membrane oxygenation was used in the 6 last cases. The mean length of resection was 81 mm [50-120 mm]. There was no 30-day postoperative mortality. A complete resection (R0) was achieved in 11 patients. The main late complications consisted of tracheal granulomas related to the stent and requiring repeated bronchoscopies (n=9), pneumonia (n=3), airway infection (n=1), bronchoesophageal fistula (n=1), mechanical stent obstruction requiring change (n=2), and mediastinitis treated by antibiotics, drainage, and omentoplasty (n=1). With a maximal follow-up of 3years and 7months, cancer recurrence was observed in 2 patients. All patients were alive at last follow-up except 2 (84.6%). Airway replacement using stented CAA represents a feasible and promising solution for extensive tracheal cancer.

S2808 Endoscopic Management of Boerhaave Syndrome Complicated by Bronchoesophageal Fistula

S2808 Endoscopic Management of Boerhaave Syndrome Complicated by Bronchoesophageal Fistula

319. A SUCCESSFUL CASE OF VACUUM-STENT TREATMENT FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY WITH COMPLICATED POST-SURGICAL COURSE

Abstract Background Anastomotic leakage after esophagectomy is associated with severe morbidity. Endoscopic vacuum therapy (EVT) has gained a greater role in endoscopic treatment of these defects and is most often applied using endoscopically placed vacuum-sponges. Recently, the vacuum-stent was introduced as a new device to apply EVT, combining the benefits of negative pressure wound therapy and an intraluminal stent, while allowing for oral intake of a soft diet. Methods This video describes a patient with anastomotic leakage after esophagectomy with complicated post-surgical course, successfully treated with a vacuum-stent, including the technical aspects of the technique. First, a guidewire was placed and the vacuum-stent was advanced over the guidewire and introduced into the esophagus. The vacuum-stent was placed over the defect and deployed using the distal release system. Lastly, the vacuum-stent was connected to a vacuum pump, which was set to a pressure of -125 mmHg on the day of placement and -75 mmHg from the second day on. Generally, the vacuum-stent was removed after 7 days. If the defect persisted, another vacuum-stent was placed. Case/Results: A 65-year-old female had undergone a minimally invasive esophagectomy with gastric conduit reconstruction and intrathoracic anastomosis. Post-surgically, the patient had dysphagia due to an elongated gastric conduit, only improving after stent placement. However, this caused a stent-induced broncho-esophageal fistula and was no definite treatment. Therefore, she underwent surgery to close the fistula with a bovine patch and gastric conduit re-construction. A prophylactic vacuum-sponge was placed, but 8 days post-surgery, endoscopy showed a dislocated sponge and dehiscence of the complete anastomosis. A vacuum-stent was placed. After 3 vacuum-stents in 20 days, the defect had closed endoscopically, which was confirmed by CT-scan with oral contrast. Conclusions The vacuum-stent seems to be a safe and possibly organ-saving treatment option for anastomotic leakage after esophagectomy. Link to video: https://we.tl/t-eOVEhUiwge

Thoracoscopic approach as surgical management of esophageal epiphrenic diverticulum.

Management of diverticulum of the lower esophagus or epiphrenic diverticulum can be performed using the abdominal or thoracic approach. In some cases, the thoracic approach is preferred, but few studies have described thoracoscopic resection. The objective of the present study was to investigate the thoracoscopic approach for management of epiphrenic esophageal diverticulum. From 2008 to 2018, all patients undergoing surgery for epiphrenic esophageal diverticulum by the thoracoscopic approach were included in this single-center, retrospective, observational study. Data on diverticulum, surgery and follow-up were assessed. During the study period, 14 patients underwent surgery. Two patients had two diverticula. The mean location of the superior edge of the diverticulum was 7cm (2-14cm) above the gastro-esophageal junction. The mean size of the diverticulum was 39 millimeters (20-60). Thoracoscopic approach was used in all patients. No conversion to thoracotomy was required. Mean operative time was 168min (120-240). No postoperative mortality occurred. The overall complication rate was 40% (6 complications out of 15 resections), with three major complications including leaks (n=2) and a case of bronchoesophageal fistula (n=1). Median length of hospital stay was 12 days (8-40). At a mean postoperative follow-up of 20.7 months (5-71), 85% of patients had complete disappearance of preoperative symptoms without recurrence of the diverticulum on the barium swallow study test. Thoracoscopic approach as management of epiphrenic diverticulum is feasible, with acceptable short-term morbidity. The thoracoscopic approach is also effective in resolving preoperative symptoms.

Use of the Intercostal Artery-based Latissimus Dorsi Muscle for Intrathoracic Reconstruction after Division of the Thoracodorsal Vessels and Latissimus Dorsi Muscle.

The latissimus dorsi muscle is the workhorse flap for intrathoracic reconstruction. Prior thoracotomy, which divides the latissimus dorsi muscle, limits the muscle's intrathoracic reach. We present our experience using the distal portion of the muscle for intrathoracic reconstruction based off an intercostal vessel. We also demonstrate the ability of this intercostal perforator to allow for chimeric flap elevation with a separate skin paddle, depending on the branching pattern of the intercostal vessels. This study provides a case series of three consecutive patients, treated between September 2021 and June 2022. The intrathoracic pathology addressed in these patients are bronchopleural fistula, aortoesophageal fistula, and bronchoesophageal fistula. All patients had the resolution of symptoms related to intrathoracic fistulae and did not experience recurrence. This novel pedicled muscle flap can be an additional option for patients with prior thoracotomy and avoids the morbidity which can be seen with the serratus or rectus abdominis muscle flaps.

Neoadjuvant tislelizumab plus chemotherapy for resectable locally advanced esophageal squamous cell carcinoma (ESCC): Interim analysis of a phase 2 study.

e16087 Background: Esophageal cancer (EC), as the sixth most frequently diagnosed cancer and the fourth leading cause of cancer death, poses a major health threat in China. Neoadjuvant treatment is recommended for resectable diseases with high recurrent risks; however, benefits with platinum-doublet chemotherapy are modest. Although the addition of tislelizumab, a anti-PD-1 antibody to chemotherapy has shown survival benefit in unresectable or metastatic EC, data are lacking to support such combination as a neoadjuvant modality. Here, we report the interim analysis of efficacy and safety of a prospective, phase 2 clinical trial evaluating tislelizumab plus chemotherapy as neoadjuvant treatment for locally advanced ESCC. Methods: Adults with clinical stage II-IVA (T3-T4 and/or node positive), potentially resectable ESCC, ECOG PS 0-1, and no known PD-1 expression were enrolled to receive tislelizumab (200mg) plus chemotherapy (docetaxel 75mg/m2 plus cisplatin 75mg/m2 or carboplatin AUC = 5 if CCr < 60ml/min) every 3 weeks for 4 cycles. Adjuvant tislelizumab up to 9 months were optional according to patients’ will. The primary endpoint was pathological complete response (pCR). Secondary endpoints include R0 resection, disease free survival (DFS), adverse events (AE), and biomarkers for predicting efficacy. Results: Between November 11, 2020 and Feburary 10, 2023, 28 patients with clinical stage III (n = 13) or IVA (n = 15) diseases were enrolled. 27 completed neoadjuvant treatment and 5 withdrew early because of disease progression (n = 2), serious AEs (n = 2) and bronchoesophageal fistula (n = 1). 21 patients underwent McKeown MIE and 20 (95.2%) acheived R0 resection. One patient was awaiting surgery. pCR (ypT0N0) was achieved in 33.3% (7/21) patients. According to the CAP tumor regression grading system, 3 (14.3%) cases were categorized as grade 1, 7(33.3%) were categorized as grade 2 and 4 (19%) were categorized as grade 3 in primary tumor. Most treatment related AEs (TRAEs) during neoadjuvant setting were mainly of grade 1 or 2. Grade 3 or 4 TRAEs occurred in 37.0% patients (10/27) and 14.8% (4/27) was considered immune-related. Surgical complications of any grade occurred in 4 patients (19.0%), 3 of which were grade 3. No grade 5 events were noted. 14 (66.7%) patients were able to continue adjuvant tislelizumab after surgery. Conclusions: Neoadjuvant tislelizumab plus chemotherapy has achieved encouraging pCR rate and tolerable safety activity in this study. Clinical trial information: ChiCTR2100043772 .

Endoscopic Treatment of a Broncho-Esophageal Fistula after Sclerotherapy Injection for Acute Variceal Bleeding

Endoscopic Treatment of a Broncho-Esophageal Fistula after Sclerotherapy Injection for Acute Variceal Bleeding

Characteristics and Outcomes of Surgical Treatment for Bronchial Anomalies.

Bronchial anomalies are rare but challenging conditions to treat in children, encompassing a variety of structural abnormalities that could compromise airway patency. This includes complete rings, absent cartilage, traumatic avulsions, bronchoesophageal fistulas, and cartilaginous sleeves. The objective of this study is to describe the characteristics and outcomes of a series of pediatric cases of bronchial anomalies that were treated by slide tracheobronchoplasty. This is a single-institution retrospective case series of pediatric patients with bronchial anomalies who underwent surgical treatment between February 2004 and April 2020. Data extracted from electronic medical records included patient demographics, comorbidities, and surgical outcomes. There were a total of 29 patients included in the study, of which 14 had complete bronchial rings, 8 had absent bronchial rings, 4 had traumatic bronchial avulsions, 2 had bronchoesophageal fistulas, and one had a cartilaginous sleeve. Median follow-up time was 13 months (with a range of 0.5-213 months). The overall mortality rate was 17.2% (5 patients), all of whom had complete bronchial rings. Patients with complete bronchial rings also had a higher rate of not only cardiac (85.7%) and pulmonary comorbidities (85.7%) but also secondary airway lesions (78.6%). This is the largest series to date describing surgical treatment for bronchial anomalies. Complete bronchial rings were the most common anomaly treated, followed by absent rings and trauma. Surgical treatment can be successful but mortality rates are higher in patients with complete bronchial rings, possibly due to higher rates of pulmonary and cardiac comorbidities. 4 Laryngoscope, 133:3334-3340, 2023.

Esophageal Cancer Complicated by an Oesobronchial Fistula Revealed by a Pulmonary Abscess: About One Case

Introduction: Esophageal fistula is a rare and serious complication of esophageal cancer. Observation: We report the case of a 33-year-old female patient. The reason for consultation was epigastralgia, post prandial vomiting, purulent bronchial syndrome and fluid dysphagia. Clinical examination revealed a right basal fluid effusion syndrome and limited mouth opening. Thoracic imaging showed a right pulmonary abscess complicating a bronchoesophageal fistula. The digestive fibroscopy showed a necrotizing circumferential budding tumor of the lower third of the esophagus with an orifice on the right side of the esophagus communicating the esophagus and the right basal pyramid. The patient benefited from a feeding gastrostomy. The evolution was marked by the death of the patient three months after her treatment by a cardiorespiratory arrest. Conclusion: Esophageal fistula is a complication of the pre-terminal stage of esophageal cancer. The diagnosis is made by endoscopy and imaging. The treatment remains palliative at this stage.

BRONCHOESOPHAGEAL FISTULA IN SHEEP – CASE REPORT

The term bronchoesophageal fistula is used for the abnormal communication between the esophageal lumen and the pulmonary bronchi. There are no reports of this condition in production animals, and its origin is unknown. A male Dorper sheep from the Veterinary Hospital of the Santo Amaro University, SP, Brazil, presented clinical signs of tachypnea, apathy, and coughing after eating. The animal died suddenly after a fever break. During the gross evaluation, a fistula was noticed in the middle third of the thoracic esophagus with communication to the right cranial lung lobe, forming an encapsulated area measuring 24.5 cm x 22.0 cm x 9.4 cm. Fibrous tissue delimited the pulmonary lobe and feed filled the compartment. This is a rare condition with unclear etiopathogenesis.

Tubercular bronchoesophageal fistula

We present a commentary on bronchoesophageal fistulas (BOF) in children as per our experience in a sixteen-year-old girl with tubercular BOF. Acquired BOF in literature have been mostly described post traumatic or in association with malignancies in children.

Language concordance in healthcare: Beyond just talk.

If you talk to someone in a language they understand, you speak to their head. If you talk to them in their own language, that goes to the heart. Image credit: African Paediatric Fellowship Program www.apfp.uct.ac.za One, a 7-year boy, COVID-19 positive, with severe lobar pneumonia and poor treatment response. Repeated questioning was negative for history of choking and, complicating the situation, bronchoscopy was not easily accessible as the hospital was tackling a COVID-19 surge. When the bilingual doctor discussed it again with the family in their home language, they better understood what the concern was and were able to say that he had in fact swallowed a pen-top around the time the symptoms started. Safe bronchoscopic removal of this was expedited with excellent outcome. Another encounter was of a parent from a neighbouring country refusing gastrostomy feeding for their infant with severe laryngeal incompetence, despite extensive counselling. The mother spoke very good English and she and attending doctors insisted she understood the situation, but she still refused the advice. When we arranged a colleague who spoke her home language to talk with her about it, she was able to voice her fear about what the procedure would mean for her and her child returning home. We were then able to address this and safely connect her with the appropriate care back in her home country. The third case, an angry mother wanting to discharge her child against medical advice. Her child had a healing broncho-oesophageal fistula secondary to severe pulmonary TB, which required a complicated feeding regimen. When given the opportunity to speak to a doctor in her home language she was able to say how she had felt the doctors were not listening to her and that she actually had a very good idea of how to care for her child safely—she proved us right. Language-concordant care, increased access to appropriate care, empowered parents, enhanced trust in the doctors and lead to improved health outcomes. Language-discordant care goes beyond threats to informed consent (which regrettably persist particularly in areas with limited clinician-patient language concordance), it threatens health outcomes and perpetuates health inequity for diverse populations. The world is wonderfully linguistically diverse, with over 7000 languages spoken worldwide: Chinese, English, Hindi, Spanish and Arabic being the five most spoken. Our communities are increasingly ethnically and culturally diverse, making the power to interact and communicate with each of increasing value. Historical and current inequities have impaired trust between communities and language plays a powerful role in healing this. Language-discordant healthcare is often borne by the most disadvantaged, highlighting the crucial importance of addressing this in advancing health equity. None declared.

December 2022 Medical Image of the Month: Bronchoesophageal fistula in the Setting of Pulmonary Actinomycosis

No abstract available. Article truncated after 150 words. A 65-year-old woman, never smoker with hypothyroidism, hypertension, anxiety, and depression disorders, initially presented to the emergency department with progressive nonspecific chest discomfort for two days. She had CT Angio, which was negative for PE but showed a 4.6 cm subcarinal centrally necrotic nodal mass (Figure 1A-B). She was subsequently advised to follow up with her primary care physician. A week later, she attended our emergency department again with a new intermittent cough and one episode of non-bloody emesis. She reported a sensation of drowning with the intake of liquids and subsequent intractable coughing. Otherwise, she did not have other associated symptoms such as shortness of breath, abdominal pain, fever, sweats, or chills. Vital signs and physical exam were unremarkable. A repeat chest CT was performed, which demonstrated internal cavitation of the subcarinal mass with fistulous communication between the lumen of the midthoracic esophagus and the proximal left mainstem bronchus …