Esophageal Fistula Formation Research Articles

Esophageal injury, perforation, and fistula formation following atrial fibrillation ablation.

Esophageal perforation and fistula formation are rare but serious complications following atrial fibrillation ablation. In this review article, we outline the incidence, pathophysiology, predictors, and preventative strategies of this dreaded complication. We conducted an electronic search in 10 databases/electronic search engines to access relevant publications. All articles reporting complications following atrial fibrillation ablation, including esophageal injury and fistula formation, were included for systematic review. A total of 130 manuscripts were identified for the final review process. The overall incidence of esophageal injury following atrial fibrillation ablation was significantly higher with thermal ablation modalities (radiofrequency 5-40%, cryoballoon 3-25%, high-intensity focused ultrasound < 10%) as opposed to non-thermal ablation modalities (no cases reported to date). The incidence of esophageal perforation and fistula formation with the use of thermal ablation modalities is estimated to occur in less than 0.25% of all atrial fibrillation ablation procedures. The use of luminal esophageal temperature monitoring probe and mechanical esophageal deviation showed protective effect toward reducing the incidence of this complication. The prognosis is very poor for patients who develop atrioesophageal fistula, and the condition is rapidly fatal without surgical intervention. Esophageal perforation and fistula formation following atrial fibrillation ablation are rare complications with poor prognosis. Various strategies have been proposed to protect the esophagus and reduce the incidence of this fearful complication. Pulsed field ablation is a promising new ablation technology that may be the future answer toward reducing the incidence of esophageal complications.

Iatrogenic oesophageal fistulas after neckregion surgery

&lt;b&gt;Introduction:&lt;/b&gt; Iatrogenic esophageal fistulas after neck surgery are a rarely discussed topic in the Polish literature. Due to the scarcity of publications on esophageal fistulas, esophageal perforation after neck surgery, the topic of this paper was undertaken. For this purpose, the literature was reviewed and a description of two cases was presented, comparing the diagnostic and therapeutic difficulties encountered to the world literature.&lt;/br&gt;&lt;/br&gt; &lt;b&gt;Case reports:&lt;/b&gt; In the cases presented, esophageal fistula formation occurred after operations in the neck. In the first case, the esophageal fistula was a complication after resection of Zenker’s diverticulum and in the second case, the fistula developed after removal of the thyroid gland. Esophageal fistulas in the described patients proved to be a major therapeutic challenge. Despite a number of repair procedures undertaken by surgeons, laryngologists and thoracic surgeons in both patients, full therapeutic success was not achieved. In the present study, the authors related the management modalities of the presented patients to the experience of other centers. Methods of treating esophageal fistulas, possible complications and ways of treating these complications are discussed.

S2398 Under Pressure: An Uncommon Case of Extraluminal Esophageal Air

Introduction: The presence of air adjacent to the esophagus on imaging can be an emergent finding warranting surgical or endoscopic evaluation, and the etiology can be esophageal, pulmonary, or vascular in nature. We report a case of an aortoesophageal fistula (AEF) in a critically ill patient after a recent thoracoabdominal endovascular aortic aneurysm repair (TEVAR). Case Description/Methods: A 70-year-old woman with hypertension and atrial fibrillation was in intensive care after a recent complicated TEVAR performed for aortic rupture. She was noted to have tachycardia and hypotension; she denied any nausea, melena, or hematochezia. Vital signs revealed a heart rate of 123 beats per minute and a blood pressure of 85/51 mm Hg. Physical exam showed a critically-ill appearing woman in no distress, a clear oropharynx, a non-tender abdomen, and a rectal exam without blood. Labs noted a leukocytosis of 19.0 x109/L, a Hgb of 6.8 g/dL, and a lactate of 2.1 mmol/L. Labs drawn 12 hours prior noted a Hgb of 8.2 g/dL and a lactate of 0.9 mmol/L. CT imaging of the chest (Figure A-B) showed interval air in the excluded thoracic aneurysmal sac adjacent to the esophagus (arrow 1), which was intubated by an enteric tube (arrow 2). EGD (Figure C-D) revealed 2 large non-bleeding perforations in the middle esophagus with possible fistulation to the mediastinum. The clinical presentation suggested post-TEVAR AEF, likely due to compressive ischemia and necrosis of the esophagus from the aneurysmal sac compounded by prolonged shock. Given high operative risk, an esophageal stent and gastrostomy tube were placed by cardiothoracic surgery. Discussion: Post-TEVAR AEF formation is a rare but serious complication occurring in 1.7–1.9% of patients after TEVAR, and can be due to graft infection, aortic pressure necrosis, or esophageal erosion related to aortic expansion. Chiari’s triad, the hallmark symptoms of AEF, include mid-thoracic pain and sentinel hematemesis followed by massive hematemesis. However, massive hemorrhage may be observed soon after a sentinel episode of hematemesis or can be delayed by years. Imaging findings include air within the aortic thrombus or esophageal wall, expanding fluid collection around the graft, or extraluminal aortic contrast extravasation. Endoscopic findings include esophageal submucosal protrusions, ulcerative lesions, or fistula formation. In stabilized patients, management options include subtotal esophagectomy and aortic debridement and reconstruction.Figure 1.: Endoscopic and Imaging Investigations for Aortoesophageal Fistula. Panels A-B. Coronal and axial, respectively, CT images of the chest with contrast. The development of air was noted in the excluded aortic aneurysmal sac adjacent to the esophagus after TEVAR (arrow 1); the esophagus is intubated by an enteric tube (arrow 2). Panels C-D. EGD revealed 2 large non-bleeding perforations in the middle esophagus with surrounding ulceration and possible fistulation to the mediastinum.

Comment on "Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials".

Comment on "Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials".

Esophageal safety in CLOSE-guided 50 W high-power-short-duration pulmonary vein isolation:The PREHEAT-PVI-registry.

Pulmonary vein isolation (PVI) using high-power-short-duration (HPSD) radiofrequency ablation (RF) is emerging as the standard of care for treatment of atrial fibrillation (AF). While procedural short-term to midterm efficacy and efficiency are very promising, this registry aims to investigate esopahgeal safety using an optimized ablation approach. In a single-center experience, 388 consecutive standardized first-time AF ablation were performed using a CLOSE-guided-fixed-50 W-circumferential PVI and substrate modification without intraprocedural esophageal temperature measurement. Three hundred patients underwent postprocedural esophageal endoscopy to diagnose and grade endoscopically detected esophageal lesions (EDEL) and were included in the analysis. EDEL were detected in 35 of 300 patients (11.6%), 25 of 35 were low-grade Kansas-city-classification(KCC) 1 lesions with fast healing tendencies. Sixpatients suffered KCC 2a lesions, 4 patients had KCC 2b lesions (1.3% of all patients). No esophageal perforation or fistula formation was observed. Patient baseline characteristics, especially patients age, gender, and body mass index did not influence EDEL incidence. Additional posterior box isolation did not increase the incidence of EDEL. In patients diagnosed with EDEL, mean catheter contact force during posterior wall ablation was higher (11.9 ± 1.8 vs. 14.7 ± 3 g, p < .001), mean RF duration was shorter (11.9 ± 1 vs. 10.7 ± 1.2 s, p < .001), while achieved ablation indexwas not different between groups (434 ± 4.9 vs. 433 ± 9.5, n.s.). Incidence of EDEL after CLOSE-guided-50 W-HPSD PVI is lower compared to historical cohorts using standard-power RF settings. Catheter contact force during posterior HPSD ablation should not exceed 15 g.

Autopsy Techniques in Patients With History of Radiofrequency Ablation for Atrial Fibrillation.

Esophageal fistula formation is one of the most feared complications of radiofrequency catheter ablation. This procedure and its many variations, such as the "maze," are becoming the mainstream treatment for atrial fibrillation owing to limitations of antiarrhythmic drugs. The incidence of this complication rate has been reported to be from 0.01% to 1%. To delineate the importance of using the en bloc Letulle method of dissection for identifying esophageal fistulas for cases with a history of radiofrequency catheter ablation. Six autopsy cases with a history of radiofrequency catheter ablation for atrial fibrillation were selected from 1736 autopsies performed between 2009 and 2020. The initial presenting symptoms included neurologic symptoms, chest pains, epigastric discomfort, and sepsis. Transesophageal echocardiogram in 4 cases showed no evidence of thrombus or vegetation, however, 2 cases had evidence of atrial esophageal fistula. The autopsy findings included 5 atrial esophageal fistulas and 1 esophagopericardial fistula. Atrial esophageal fistulas were small and could be detected without difficulty when the en bloc Letulle technique was used and would have been easily missed by the Virchow method. The immediate causes of the deaths were myocardial ischemia, septic emboli to brain and heart, hypovolemic shock secondary to exsanguination, stroke, and coagulopathy. To date, this is the largest collection of autopsy cases showing esophageal fistula associated with prior radiofrequency catheter ablation. The Letulle dissection method is preferable in this setting.

High incidence of esophageal fistula on patients with clinical T4b esophageal squamous cell carcinoma who received chemoradiotherapy: A retrospective analysis

Background and purposeDespite definitive chemoradiotherapy (CRT) being a recommended therapeutic method for patients with T4b esophageal squamous cell carcinoma (ESCC), treatment response and complications remain unclear. Esophageal fistula is a severe CRT-related complication when treating locally advanced ESCC, but data on risk factors that lead to esophageal fistula formation are limited. The aim of this analysis is to characterize the outcomes of T4b ESCC treated by CRT and investigate the risk factors of esophageal fistula. Materials and methodsWe retrospectively analyzed 136 patients with clinically unresectable T4b ESCC who were treated with CRT. Response, survival, and complication rates, particularly the rate of esophageal fistula and its associated risk factors were analyzed. ResultsThe median progression-free survival and overall survival (OS) of all patients were 7.9 (95% confidence interval [CI]: 6.1–9.7) and 12.2 months (95% [CI]: 8.9–15.4), respectively. The Kaplan–Meier curves showed that the 3- and 5-year OS rates were 29.9% and 20.2%, respectively. The incidence rate of esophageal fistulas was 30.1%. The median OS for patients with esophageal fistula was only 6.9 (95%[CI] = 6.0–7.8) months. The risk for developing esophageal fistulas was significantly high for ulcerative-type tumors (odds ratio [OR] = 3.202; 95%[CI] = 1.036–7.850, P = 0.011) and for those invading the bronchus/trachea (OR = 3.378; 95%[CI] = 1.223–9.332, P = 0.048). ConclusionWe demonstrated that CRT for T4b ESCC patients has a curative potential, despite a high incidence of esophageal fistula, which was the main cause of treatment failure. The higher risk for fistula formation were tumors with ulceration or bronchus/trachea invasion.

Esophageal Tear with Pneumomediastinum Secondary to Esophageal Candidiasis in a Patient with Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED)

Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED) is a rare condition that diffusely affects many organ systems. Chronic mucocutaneous candidiasis is one of the features of APECED, which needs to be treated and monitored to prevent severe complications. This case demonstrates esophageal structuring and resultant esophageal perforation, in the setting of chronic mucocutaneous candidiasis. Learning Points • Chronic mucocutaneous candidiasis (CMC) can be present without overt esophageal thrush • CMC can result in esophageal lesions causing significant morbidity. • APECED patients with dysphagia should be assessed for chronic candida esophagitis and treated accordingly. • Patients with recurrent candida esophagitis should be considered for intermittent topical and systemic antifungal prophylactic therapy. • Esophageal perforation due to candidiasis is most often seen in the setting of immunocompromised states. Background Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is a rare autosomal recessive disease caused by mutations of the AIRE (autoimmune regulator) genes [1, 2, 6, 7]. It is characterized by the clinical trial of chronic mucocutaneous candidiasis (CMC), hypoparathyroidism, and adrenal insufficiency [7]. APECED has been reported worldwide, but is more prevalent in some historically- isolated homogeneous populations in Finland (1/25000), Sardinia, and Iranian Jews (1/9000) [7]. APECED is also seen at a lower incidence in Norway, Sweden, Slovenia, Great Britain, Italy, Ireland, and North America [7]. Most patients have CMC from early childhood [2, 3]. Rarely, untreated esophageal candidiasis may lead to complications such as esophageal stricture, rupture and or fistula formation [4, 5].

Palliative Radiotherapy Versus Esophageal Stent Placement in the Management of Patients With Metastatic Esophageal Cancer.

Patients with advanced esophageal cancer often experience pain and dysphagia, yet the optimal palliative management remains unclear. This retrospective study evaluated outcomes and adverse effects of palliative radiotherapy (RT) compared with esophageal stenting among a cohort of U.S. veterans with metastatic esophageal cancer. We identified 1,957 veterans in the United States with metastatic esophageal cancer who received palliative RT to the esophagus or esophageal stenting, and assessed the risks of severe adverse effects, including esophageal fistula formation, perforation, obstruction, hemorrhage, and esophagitis. We determined palliative efficacy by evaluating pain and dysphagia scores before and after intervention. Multivariable analyses were used to control for potential confounding factors. In our cohort, 1,593 patients underwent RT and 364 underwent esophageal stenting. The cumulative incidence of any severe adverse effect at 6 months was higher among patients who received stents compared with those who received RT (21.7% vs 12.4%; P<.0010). In multivariable analysis, patients who received stents had an increased risk of any severe adverse effect, including fistula, perforation, and hemorrhage (all P<.0500). Multivariable analysis also showed that, compared with stenting, RT was associated with more rapid and durable pain relief (P<.0010) with no difference in relief of dysphagia over time when accounting for pretreatment dysphagia scores (P=.1029). Compared with esophageal stenting, RT was associated with a decreased risk of adverse effects, greater pain relief, and equivalent relief of moderate to severe dysphagia over time. Unmeasured patient- or tumor-related factors could have influenced the choice of intervention, thereby impacting our study outcomes. To our knowledge, this is the largest study to date analyzing the comparative risks and benefits of palliative RT and esophageal stenting among patients with metastatic esophageal cancer.

Esophageal Thermal Injury FollowingCryoballoon Ablation forAtrialFibrillation.

This study evaluated the rate and predictors of endoscopically detected esophageal thermal lesions (EDEL) in patients who underwent cryoballoon atrial fibrillation (AF) ablation (CBA). EDEL is a known complication of catheter ablation for AF and is the inciting factor for atrial esophageal fistula formation. An observational study was conducted of patients with AF presenting for CBA. Pre-procedural magnetic resonance imaging was used to retrospectively evaluate the distance between the atrial endocardium and the esophageal lumen (AED). Intraprocedural esophageal luminal temperature and balloon temperatures were recorded. All patients underwent upper endoscopy (EGD) 24h post-ablation. Clinical, anatomical, and ablation parameters were analyzed using logistic regression for association with thermal injury. A total of 95 patients (37% women; 71% paroxysmal AF) were included in the study. Esophageal thermal injury was detected on EGD in 21 patients (22%). EDEL was mostly mild (20 of 21 patients) and severe in only 1 of 21 patients. Univariate logistic regression identified gastroesophageal reflux disease to be associated with increased risk of thermal injury (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.00 to 10.46; p=0.04), whereas a wider AED was protective (OR: 0.16; 95%CI: 0.05 to 0.515; p=0.002). Esophageal wall thickness was also protective (OR: 0.04; 95%CI: 0.002 to 0.864; p=0.04). In multivariate analysis, only AED (OR: 0.22; 95%CI: 0.06 to 0.77; p=0.018) and obesity (OR: 4.63; 95%CI: 1.13 to 18.97; p=0.033) were associated with EDEL. Esophageal luminal temperature, number, and duration of cryoballoon applications and balloon temperature were not predictors of EDEL. EDEL following CBA occurred in 22% of patients and was mostly mild. Obesity and atrioesophageal distance were independently associated with increased risk.

1776 Bleach Gargling - An Effective yet Destructive Method to Beat a Drug Test: A Bizarre Case of Caustic Esophageal Injury

INTRODUCTION: Caustic alkali ingestion can result in severe esophageal injury. Extensive luminal damage may result in esophageal necrosis and eventually perforation. Historically, caustic ingestion has been seen mostly accidentally in children and in individuals with psychiatric illness. Since the new regulations against opioids, certain individuals have been creative with methods of beating those drugs tests. We present to you a case in which bleach was the culprit in induction of severe mucosal injury. CASE DESCRIPTION/METHODS: A 35-year-old male on chronic Oxycodone therapy presented with chest pain, epigastric pain, odynophagia, dysphagia for several months. He denied any history of GERD, EOE, prior EGD or recent new meds. He denied any other GI symptoms such as diarrhea, melena or hematochezia. He reported hemoptysis 3 days prior. Vitals were stable on arrival. His WBC count was 16 and CRP at 100. CT scan revealed diffuse esophageal wall thickening greatest at the upper to mid esophagus. Upon further questioning, he admitted to gargling bleach regularly for several months to falsely pass his opioid drug salivary testing as he had been illegally taking hydrocodone in addition to his prescribed oxycodone. He wasn't aware that bleach may cause any harm as he was not ingesting it. EGD revealed findings consistent with LA grade C esophagitis characterized by esophageal edema, thickening and friability which was most severe at the upper esophagus. Biopsies were taken which came back positive for active esophagitis He was sent home the next day on Protonix 40 mg twice a day with outpatient follow up. DISCUSSION: Caustic ingestion in adults can cause severe gastro-esophageal injury. The severity and extent of the damage depends upon: the amount, concentration, form and corrosive property of the agent; along with the duration of contact. Patients will present with oropharyngeal, retrosternal or epigastric pain, dysphagia/odynophagia, or hyper-salivation with or without hemoptosis. In case of perforation the pain will be severe. Initial evaluation includes history, physical examination, lab work and CT scan to determine the depth of involvement. Symptomatic patients should be hospitalized for supportive care. The use of NG tube is contraindicated. Perforation is an indication for emergent surgery, however; In the absence of a perforation EGD should be performed early. Esophageal strictures, bleeding, fistula formation and esophageal squamous cell carcinoma are known complication of caustic ingestion.

1687 Argon Plasma Coagulation-Based Removal of Partially-Covered Esophageal Self-Expanding Metal Stent for Anastomotic Leaks Despite Extended Embedment - Challenging Current Standards of Care

INTRODUCTION: Benign esophageal anastomotic leaks can be effectively treated by the placement of esophageal stents. Endoscopic therapy for esophageal anastomotic leaks remains non-standardized. Partially covered self-expanding metal stents (PSEMS) are superior to fully covered stents in the treatment of anastomotic leaks by providing a better seal and therefore promoting quicker healing with shorter time to oral intake. However, the removal of partially covered SEMS is technically challenging due to these stents’ inherent risk of stimulating mucosal hyperplasia and without special technique will lead to esophageal perforation, avulsion or fistula formation during attempted removal. Generally, anastomotic leaks require at least 4 weeks of stent dwelling for clinical success with an average treatment time of 6–8 weeks with recommendations for stent removal by 3 months. CASE DESCRIPTION/METHODS: A 69-year-old man with esophageal adenocarcinoma of the distal esophagus status post neoadjuvant chemoradiation followed by Ivor-Lewis esophagectomy with pyloroplasty presented to the hospital with hematemesis and found to have developed two anastomotic leaks within one month of surgery. He was treated with PSEMS measuring 12.5 cm × 20 mm (25 mm at ends). Three months after placement, elective EGD revealed previously placed stent covering the anastamosis with tissue ingrowth at the uncovered ends. Coagulation using argon plasma at 0.8 liters/minute and 55 watts was performed to free the uncovered ends of the stent by destruction of ingrown tissue. The proximal end was freed, however, some tissue remained over the distal end even after extensive attempts at coagulation and debridement. Two days later, the procedure was repeated with continued fulguration to ablate the remaining ingrown tissue at the uncovered ends using argon plasma and a soft over-the-scope cap was used to remove the necrosed tissue. Stent was eventually removed with rat-tooth forceps. DISCUSSION: There are many described methods for partially covered esophageal stent removal. We propose a safe and effective method for the removal of partially covered esophageal SEMS with the use of Argon Plasma Coagulation, a soft over-the-scope cap and rat-tooth forceps after an extended stent dwelling time of three months. With this efficient, safe and effective method of stent removal, it is essential that the use of partially covered esophageal SEMS be standard of care in the temporary management of anastomotic leaks. Watch the video: http://bit.ly/2SooiEC.

3102 Atrio-Esophageal Fistula Presenting as Odynophagia: A Rare but Fatal Complication of Cardiac Ablation

INTRODUCTION: Atrio-esophageal fistula is one of the challenging complications of catheter ablation. The clinical presentation is unpredictable but rapid diagnosis and surgical treatment may prevent fatality. We are here reporting a case of a patient who initially presented with odynophagia and was diagnosed later with atrio-esophageal fistula. CASE DESCRIPTION/METHODS: 43 years old male presented to ED with complaints of retrosternal chest pain and odynophagia s/p cardiac ablation for AF 4 days ago. Initial investigation were normal. Patient on upper GI series had focal contrast collection at the distal esophagus. Patient underwent EGD and it was found that patient had linear deep mid esophageal perforation for which 6 hemostatic clips were used for closure patient was discharged on TPN. After 2 weeks patient presented again for shortness of breath and chest discomfort. On examination patient had loud pericardial friction rub suspicious and stat Echo showed pericardial effusion with early signs of cardiac tamponade. Patient underwent emergent pericardiocentesis. After pericardiocentesis patient became febrile and blood cultures were growing Lactobacillus. CT chest (pulmonary veins) revealed Atrio-esophageal fistula, pericardial effusion and left sided pleural effusion suspected for empyema. Patient underwent thoracotomy, decortication of empyema, repair of inferior pulmonary vein/atrial margin, esophageal repair, G/J tube placements, and omental transfer. Patient eventually improved and was discharged home. DISCUSSION: The estimated incidence of atrio-esophageal fistula is less than 0.1% – 0.25% after AF ablation procedures. Potential culprit is direct heat of radiofrequency ablation causing damage to already susceptible epithelial esophageal mucosa. After esophageal mucosal necrosis, fistula formation and mediastinitis can occur. Pericardial effusion/tamponade, sepsis and cardioembolic stroke can also occur. Patient may present with fever, nausea, vomiting, dysphagia, odynophagia, hematemesis and melena. CT scan of the chest with intravenous contrast is considered by many as the diagnostic modality of choice as it can identify the leak along with any signs of pneumomediastinum and pneumopericardium. Endoscopy should be avoided as blowing of air inside can result in dislodging of the large embolus to the brain resulting in stroke or death. Treatment options include open surgical repair of fistula via thoracotomy with placement of tissue/omentum between esophagus and left atrium or esophageal stenting.

Relationship between nutritional status and esophageal fistula formation after radiotherapy for esophageal cancer

PurposeChemoradiotherapy and radiotherapy for esophageal cancer sometimes cause esophageal fistulas. Esophageal fistulas often require additional procedures and are associated with a high mortality rate. The present study was conducted to determine the risk factors associated with esophageal fistulas in patients with esophageal cancer. Patients and methodsWe reviewed the cases of 206 patients who were treated with definitive radiotherapy for esophageal cancer. The planning dose, which ranged from 44 to 64.8Gy (median: 59.4Gy), was delivered to the primary lesion and regional lymph nodes. Descriptive statistics were calculated, and time-to-event analyses were performed using Cox proportional hazards regression analysis. ResultsNone of the 68 patients with T1 or T2 esophageal cancer developed esophageal fistulas. Among the 138 patients with T3 or T4 esophageal cancer, esophageal fistulas were detected in 20 (14.5%) patients. Multivariate analysis of the 138 patients with T3 or T4 esophageal cancer revealed low body mass index (BMI) to be an independent risk factor for esophageal fistula formation (P=0.0055). The optimal BMI cut-off value for predicting esophageal fistula formation was 20 kg/m2 (P=0.0121, odds ratio=4.130). ConclusionIn patients with esophageal cancer treated with definitive radiotherapy, a BMI below20kg/m2 is a risk factor for esophageal fistula formation. A well-designed randomized controlled trial comparing the incidence of esophageal fistulas between patients with esophageal cancer who do and do not receive nutritional support before radiotherapy is required.

Esophageal Metal Stents with Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Safe or Not?

The purpose of this study was to review the risks and benefits of concurrent chemoradiation therapy (CCRT) with esophageal self-expandable metal stents (SEMS) for the treatment of locally advanced esophageal cancer. Between January 2014 and December 2016, the data from 46 locally advanced esophageal cancer patients who received CCRT at our institution were retrospectively reviewed. Eight patients who received CCRT concomitant with SEMS placement (SEMS plus CCRT group) and thirty-eight patients who received CCRT without SEMS placement (CCRT group) were identified. The risk of developing esophageal fistula and the overall survival of the two groups were analyzed. The rate of esophageal fistula formation during or after CCRT was 87.5% in the SEMS plus CCRT group and 2.6% in the CCRT group. The median doses of radiotherapy in the SEMS plus CCRT group and the CCRT group were 47.5 Gy and 50 Gy, respectively. SEMS combined with CCRT was associated with a greater risk of esophageal fistula formation than CCRT alone (hazard ratio [HR], 72.30; 95% confidence interval [CI], 8.62-606.12; p < .001). The median overall survival times in the SEMS plus CCRT and CCRT groups were 6 months and 16 months, respectively. Overall survival was significantly worse in the SEMS plus CCRT group than in the CCRT group (HR, 5.72; 95% CI, 2.15-15.21; p < .001). CCRT concomitant with SEMS for locally advanced esophageal cancer results in earlier life-threatening morbidity and a higher mortality rate than treatment with CCRT alone. Further prospective and randomized studies are warranted to confirm these observations. Patients treated with SEMS placement followed by CCRT had higher risk of esophageal fistula formation and inferior overall survival rate compared with patients treated with CCRT alone. SEMS placement should be performed cautiously in patients who are scheduled to receive CCRT with curative intent.

Transcatheter arterial embolization for intercostal arterio-esophageal fistula in esophageal cancer

BackgroundWhile esophageal fistula formation in the adjacent organs is associated with high rates of morbidity and mortality, the management of non-aortic arterio-esophageal fistula has not been frequently reported.Case presentationA 69-year-old Japanese man who had undergone definitive chemoradiotherapy for esophageal cancer was admitted to our hospital with hematemesis. He was diagnosed with mediastinal abscess caused by esophageal perforation, and esophageal bypass surgery was performed. After 3 days, he presented with fatal hemoptysis. As angiography revealed an intercostal artery pseudoaneurysm, transcatheter arterial embolization was performed.ConclusionsWhen patients with esophageal cancer, especially those with a history of radiotherapy and/or mediastinitis, present with hematemesis and/or hemoptysis, the possibility of non-aortic arterio-esophageal fistula should be considered. Transcatheter arterial embolization is an effective treatment for non-aortic arterio-esophageal fistula.

Acute fever and seizure in a patient with recent atrial fibrillation ablation

Patients undergoing radiofrequency ablation for treatment of atrial fibrillation may present critically ill with complications of atrial esophageal fistula, commonly manifesting as neurologic deficits and septicemia difficult to distinguish from other acute etiologies without a high index of suspicion. The temporal variability in fistula formation and symptom presentation, along with their nonspecific features, makes diagnosis often a late finding with historically high morbidity and mortality. We present a patient admitted to a medical intensive care unit with status epilepticus and recurrent positive blood cultures for organisms commonly associated with the gastrointestinal (GI) tract. Chest computed tomography (CT) without contrast, transthoracic echocardiography, and initial neurologic imaging were unhelpful. A diagnosis was ultimately made by upper endoscopy of the esophagus after hematemesis with suspicion for GI bleed, at which point surgical intervention was attempted but without success. This case reviews the clinical features of atrial esophageal fistula formation and its initial diagnosis and management.

Pneumopericardium Following Radiofrequency Ablation for Atrial Fibrillation: Insights into the Natural History of Atrial Esophageal Fistula Formation

We present a case of large pneumopericardium resulting from an esophageal pericardial fistula following ablation for atrial fibrillation (AF). The presentation, evaluation, and management of this specific patient, along with a review of present techniques to diagnose esophageal injury, provide a unique insight into the pathophysiology of left atrial-esophageal fistula formation.

Recessive dystrophic epidermolysis bullosa showing esophageal stricture

Dystrophic epidermolysis bullosa(DEB) is characterized by frequent erosive hemorrhagic bulla, scarring, malformation of hair, nail and tooth, acral deformity and considerable morbidity. Especially, DEB with recessive inheritance(RDEB) invariably discloses more extensive skin involvement and extracutaneous manifestation such as esophageal stricture or squamous cell carcinoma than in dominant DEB(DDEB). To the best of our knowledge, cases of RDEB accompanied by esophageal complications have been rarely reported in Korea. Herein, we report a rare case of EDEB showing esophageal fistula and stricture formation.

Neck Pain and Stiffness in a Toddler With History of Button Battery Ingestion

Button batteries within the gastrointestinal system are dangerous and must be suspected after any foreign body ingestion. Common complications include esophageal perforation, fistula formation, and esophageal scarring. Spondylodiscitis resulting from button battery ingestion is extremely rare and, to our knowledge, has been described in the literature only once to date. We will describe a case in which a 14-month-old girl developed spondylodiscitis of T1/T2 after an uncomplicated clinical course involving the ingestion and removal of an esophageal button battery. Discussion will include mechanisms in which button batteries cause harm and notable differences between the previously reported case and ours. We present this case to increase awareness of spondylodiscitis in patients with neck pain or stiffness and a history of button battery ingestion.