Esophageal-pleural Fistula Research Articles

Is malignant pleural mesothelioma a surgical disease? A review of 83 consecutive extra-pleural pneumonectomies☆☆☆

To report on the experience with radical surgery, with emphasis on the long-term outcome, for malignant pleural mesothelioma (MPM) at a single institution. From our prospective database over a 17-year period, we reviewed 83 consecutive patients undergoing radical surgery for MPM in a multimodality programme. The long-term overall survival was analysed using the Kaplan-Meier method. A total of 83 patients (65 males, median age: 60 years) underwent an extra-pleural pneumonectomy (EPP) with a curative intent. Epitheliod MPM was the most frequent (82%) cause. A right-sided disease was present in half of the cases (n=42). The International Mesothelioma Interest Group (IMIG) stage of the disease was 2 in 36%, 3 in 45% and 4 in 9% of the cases. Preoperative chemotherapy consisting of a doublet cisplatin-pemetrexed (mean of three cycles) was offered to 10 patients (12%). Postoperative therapies, either chemotherapy or radiotherapy, were given in 25 patients (30%). The 30-day and 90-day mortality rates were 4.8% and 10.8%, respectively. Postoperative complications occurred in 39.8% and were major in 23 patients (27.7%). Re-operation was necessary in 12 cases (14.5%) for one of the following reasons: broncho-pleural fistula (n=4), bleeding (n=3), diaphragmatic patch rupture (n=3), oesophago-pleural fistula (n=1) and empyaema (n=1). The mean hospital stay was 43 days. The median survival was 14.5 months, while the overall 1-, 2- and 5-year survival rates were 62.4%, 32.2% and 14.3%, respectively. These results concur with the published data of the most experienced centre with regards to the mortality and morbidity after EPP for MPM. In line with the biggest series reported in the past, the observed 5-year survival rate of almost 15% is disappointing.

Severe toxicity after permanent radioactive seed implantation for mediastinal carcinoid tumors

Purpose Permanent implantation of 125I seeds may be used when uninvolved surgical margins are unobtainable or close. Two cases of mediastinal carcinoid tumors with prior chemoradiation had tumors adherent to esophageal muscularis. Both underwent intraoperative permanent seed implantation and developed esophageal fistulas requiring surgical correction. Methods and materials Custom permanent 125I seed mesh implants were fashioned intraoperatively in a geometrically coherent pattern. The implants were directly sutured to the partially resected esophageal wall. The postimplant CT scans were fused with the postfistula scans to provide dosimetric information at the fistula site. Doses were calculated from time of insertion to time of fistula formation. Neither patient showed evidence of disease recurrence at the time of fistula repair. Results Patient 1 developed an esophageal-pleural fistula 83 days after seed implantation. Patient 2 developed a broncho-pleural fistula 300 days after seed implantation. Conclusions These cases demonstrated that implantation in the setting of extensive subcarinal space dissection and partial esophageal wall resection could cause fistula formation and the need for additional surgery. The high mucosal dose, despite the relatively low activity implant, was due to lack of geometric sparing of the mucosa. We recommend that extensive subcarinal space dissection be considered a contraindication to permanent seed implantation.

Mediastinal position and air-fluid height after pneumonectomy: the effect of the respiratory cycle.

After pneumonectomy, a shift of the mediastinum toward the nonoperated side may be the initial indicator of a postoperative problem such as empyema, bronchopleural fistula, esophageal-pleural fistula, hemothorax, or recurrent tumor. Postoperatively, a drop in the fluid level on the operated side may indicate a bronchopleural fistula or other fistulous connection. To assess the effect of the respiratory cycle on these two signs, 16 patients were studied with inspiration-expiration films. In every case the mediastinum shifted toward the normal side in expiration, and in no case did a fluid level change position by more than 5 mm with respiratory maneuvers. Therefore, the respiratory phase must be considered when assessing the significance of mediastinal shift after pneumonectomy.

Oesophago-pleural fistula complicating a case of tuberculous pyopneumothorax

The case of a 3-year-old girl who developed an oesophago-pleural fistula following tuberculous pyopneumothorax is described. She was successfully managed with a prolonged course of antibiotics and antituberculosis chemotherapy, followed by surgical closure of the fistula.

Iatrogenic esophageal-pleural fistula: subtlety of diagnosis in the absence of mediastinitis.

Seven patients with iatrogenic esophageal-pleural fistulas are described, and the differences in radiographic and physical findings in these patients and in patients with esophageal perforation with mediastinitis are emphasized. Radiographic findings in patients with esophageal pleural fistulas are pneumothorax, hydropneumothorax and localized pneumonitis. These fistulas can mimic other inflammatory supradiaphragmatic or infradiaphragmatic processes. Clinical and radiographic signs may be subtle, and active investigation is needed to establish the diagnosis of esophageal-pleural fistula in patients who have undergone esophageal manipulation.

Oesophageal diverticula. A follow-up study of 34 patients.

Of the 34 patients treated surgically for oesophageal diverticula during a 17-year yperiod, 14 had Zenker's and 20 thoracic diverticula. In addition to three diverticular perforations, the selection of the patients for surgery was based on major symptomatology and roentgenological retention in the diverticulum. The most usual method was a simple diverticulectomy. One patient was lost because of an oesophagopleural fistula, while non-lethal complications occurred in 10 patients. Twenty-nine patients were available for the follow-up study, which was made, on an average, 5.5 years postoperatively. Four had died of other causes. Seventeen patients regarded the results as good and 11 as acceptable. A roentgenological recurrence was detected after six Zenker's and four thoracic diverticulectomies by using the hypotonic double contrast method. Most recurrences caused only minor symptoms, if any. Two new diverticula were found in addition to the recurrences. Only one patient was reoperated on, while the slight discomfort felt by the others was not considered an indication for surgery.

Post-pneumonectomy oesophageal fistula.

The complication of oesophagopleural fistula is described in eight of 1,389 patients (0·5%) who underwent pneumonectomy for carcinoma of the bronchus. All the patients had a right pneumonectomy performed and seven of the eight patients developed a bronchopleural fistula before developing an oesophageal fistula. The complication appeared between two weeks and 22 months after pneumonectomy. All the fistulae occurred on the right side; three were at the level of the bronchial stump and five were within 5 cm below the stump. The cause of the fistula was thought to be the development of a peribronchial abscess which ruptured into the oesophagus. The complication was diagnosed by the presence of food particles on the dressings in those patients with chest drains <i>in situ.</i> It was confirmed by Gastrografin swallow. The size of the fistulae varied between 3 and 8 mm. Successful immediate surgical closure of the fistula was accomplished in three patients. Feeding was continued using a gastrostomy. Five patients unfit for surgery and treated by palliative measures died.

SPONTANEOUS PERFORATION OF THE ESOPHAGUS: REVIEW OF THE LITERATURE AND REPORT OF A CASE

Excerpt Spontaneous perforation of the esophagus is a rare condition with a high mortality rate when untreated. The following patient illustrates the need for an early diagnosis and immediate surgi...