Esophagorespiratory Fistula Research Articles

Esophagobronchial fistula - A rare complication of aluminum phosphide poisoning

Aluminum phosphide is a systemic lethal poison. Fistulous communication between esophagus and airway tract (esophagorespiratory fistula) has rarely been reported in the survivors of aluminum phosphide poisoning. We report a case of benign esophagobronchial fistula secondary to aluminum phosphide poisoning, which to best of our knowledge has not been reported in the medical literature.

Esophagorespiratory Fistula Without Stricture: Palliative Treatment with a Barbed Covered Metallic Stent in the Central Airway

Purpose To compare the clinical safety and efficacy of airway placement of barbed and nonbarbed metallic stents in the treatment of esophagorespiratory fistula (ERF) without stricture. Materials and Methods The authors prospectively evaluated the clinical results of 10 patients who underwent fluoroscopically guided placement of barbed, fully covered, retrievable metallic stents in the trachea or main bronchus for treatment of ERF without stricture in the esophagus and central airway between 2007 and 2009. The authors compared these outcomes with retrospectively evaluated clinical outcomes in seven patients who underwent airway placement of nonbarbed, fully covered, metallic stents for treatment of ERF without stricture between 1998 and 2001. Study end points included stent migration and clinical success, defined as effective closure of the fistula with improved aspiration symptoms, or improvement of dyspnea, within 7 days after stent placement. Results Clinical success was observed in nine of ten (90%) of patients who received barbed stents, compared with two of seven (29%) who were treated with nonbarbed stents ( P = .035). Stent migration within 5 days occurred in zero of ten and five of seven (57%) patients, respectively ( P = .015). Conclusions Placement of barbed, covered metallic stents in the central airway is safe and effective for closure of ERF without strictures. The barbed design is effective in preventing stent migration.

Argon plasma coagulation combined with covered stent placement for management of tracheobronchial stenoses/occlusions as well as esophagorespiratory fistulas

背景与目的气管下端、隆突和双侧主支气管发生的狭窄称为多发性狭窄或复合狭窄，治疗非常棘手。本研究旨在探讨氩等离子体凝固(argon plasma coagulation, APC)联合分叉型被膜金属内支架(covered Z-type stents, CZTS)置入治疗气管隆突周围狭窄和气管食管瘘的安全性和疗效。方法回顾性分析32例气道病变的患者，在支气管镜引导下行APC，在X线透视和/或支气管镜引导下置入CZTS。结果19例伴有气道狭窄的患者先行APC，术前气道狭窄发生率为57.4%-72.1%，术后均明显缓解(气道狭窄发生率仅为12.8%-25.8%)。32例患者中30例技术上成功放置32个支架，2例失败。APC及成功放置支架的患者术后气促指数明显下降，KPS明显升高。13例气管下端瘘口置入分叉型CZTS，12例(92.3%)达临床治愈。术中、术后未出现大出血等并发症。两种术式术后短期内均产生大量分泌物，用气管镜可有效清除。置入内支架的患者1个月后易在支架两端形成肉芽，用APC结合冷冻可有效处理。结论使用APC联合CZTS置入治疗气道复合狭窄和气管食管瘘快速有效，安全可靠。

An Endoscopic Repair Option for Acquired Esophagorespiratory Fistulas

Benign acquired esophagorespiratory fistulas (BERFs) represent a broad spectrum of anatomic pathology presenting in a wide variety of clinical settings. These fistulas can lead to severe respiratory compromise and rarely close spontaneously. Surgical fistula closure has been the traditional therapeutic approach, but is associated with significant morbidity and mortality. The recent advent of endoscopic technologies suggests that minimally invasive procedures may offer a safe alternative to surgery for the treatment of esophagorespiratory fistulas. In this article, we present our experience in treating complex benign esophagorespiratory fistulas of diverse etiologies utilizing a primarily minimal invasive, endoscopic, or combined surgical and endoscopic approaches. Our experience demonstrates that an endoscopic-based approach is safe and technically feasible and can, potentially, spare a subset of patients from open surgery. A multidisciplinary decision-making process, based on individualized parameters, is a prerequisite for a successful outcome.

Complications of Metallic Stent Placement in Malignant Esophageal Stricture and Their Management

At the present time, covered self-expandable metallic stent placement is the palliative treatment method for inoperable esophageal cancer. However, life-threatening early and late complications are seen related to esophageal stent placement. In this study, we discuss complications of esophageal stent placement with their management and present our own experience. Between January 2000 and February 2009, 215 covered esophageal stent placements were performed in 174 inoperable esophageal cancer and/or esophagorespiratory fistula patients in the Department of Thoracic Surgery at the Ataturk University Hospital. Major complications related to stent placement developed in 24 patients (11 bleeding, 6 aspiration pneumonia, 3 tracheal compressions, 2 perforations, and 2 esophagorespiratory fistulas). Two hundred and thirty minor complications were observed among 174 patients (165 chest pain, 29 tumoral overgrowth, 17 stent migration, 6 gastroesophageal reflux, 3 failure in stent placement, 3 hiccup, 2 foreign body sensation, 2 failure in stent expansion, 1 tumor ingrowth, 1 granulation tissue formation, and 1 food bolus obstruction). Reintervention was required in 56 (32.2%) patients who experienced complications. Stent-related mortality was seen in 4 (2.3%) patients (2 aspiration pneumonia, 1 tracheal compression, and 1 esophagorespiratory fistula). One hundred sixty-two of 174 patients died during follow up. The mean survival time was 177.3+/-59.3 days (range: 2 to 993 d). The complication rate of self-expandable metallic stent placement is high in inoperable esophageal cancer patients. Although some of these complications are life threatening, many of them can be managed successfully with endoscopic reintervention.

Self-expanding metal stents in palliation of malignant dysphagia: outcome of 124 Egyptian patients

Most cases of esophageal carcinoma are inoperable at presentation. Currently, the best method for palliation of malignant dysphagia, with or without esophago-respiratory fistula, is an insertion of esophageal self-expanding metal stents (SEMS) across the malignant esophageal stricture. Herein we present our experience in the use of SEMS in palliation of patients with malignant dysphagia and/or ERF. The study included 124 patients (79 males and 45 females) with advanced esophageal malignancy. The mean age was 54 (43-87) years. Nine patients had malignant ERF. All patients were subjected to SEMS insertion under both endoscopic and fluoroscopic guidance. SEMS insertion was successful in all patients. Nine patients had two stents. Median dysphagia score improved from 3.5 to 1.2. ERF was sealed in eight out of the nine patients. Complications related to stent implementation were reported in 41 patients. In conclusion, insertion of the SEMS is a reliable, effective, simple and safe method for palliation of malignant dysphagia with or without ERF.

Interventional Management of Esophagorespiratory Fistula

An esophagorespiratory fistula (ERF) is an often fatal consequence of esophageal or bronchogenic carcinomas. The preferred treatment is placement of esophageal and/or airway stents. Stent placement must be performed as quickly as possible since patients with ERFs are at a high risk for aspiration pneumonia. In this review, choice of stents and stenting area, fistula reopening and its management, and the long-term outcome in the interventional management of malignant ERFs are considered. Lastly, a review of esophagopulmonary fistulas will also be provided.

Clinical implications of esophagorespiratory fistulae in patients with esophageal squamous cell carcinoma (SCCA)

In this retrospective study, we investigated the incidence of esophagorespiratory fistula (ERF) in esophageal squamous cell carcinomas, clinical characteristics and outcomes of esophageal cancer patient with ERF, and effective therapeutic options. From 1998 to 2007, 1,095 patients with squamous cell carcinomas of the esophagus were treated at Samsung Medical Center. A comprehensive retrospective review of all these patients with clinical data of ERF was performed. The incidence of ERF in patients with esophageal cancer was 4.7% (52/1095). Comparing with the patients without ERF, the patients with ERF presented with a more advanced stage of disease, more frequent involvement of upper-mid thoracic esophagus, a longer segment of the tumor, and more initial airway involvement. The median time from the diagnosis of esophageal cancer to the development of a fistula was 7.9 months. ERF could be divided into three different categories according to the causes; (1) ERF associated with complication of the cancer progression (65.4%), (2) ERF related with treatments (28.8%), (3) ERF with mixed causes (5.8%). Four patients (8%) received radiation therapy, and nine patients (17%) underwent surgery to treat the ERF. Many of the patients with ERF were palliated with esophageal stent (40%) and/or gastrostomy (38%). The median survival time after diagnosis of the ERF was 8.0 weeks. An ERF resulting from esophageal cancer entails a poor prognosis in spite of supportive and/or definitive treatment. More comprehensive approach to improve the course of ERF and active supportive care, which can prevent complication from leakage, should be developed.

Palliative Management of Esophagorespiratory Fistula in Esophageal Malignancy

Esophagorespiratory fistula (ERF) is a complication of an esophageal malignancy that has serious effects on the mortality of a patient, whose survival is limited to weeks. Sealing of fistula and recovery of swallowing has greater importance than treating underlying primary malignancy. In this study, we aimed to present our clinic experience in patients with ERF and to discuss the findings together with the literature. Between January 2003 and December 2008, 326 patients with malignant esophageal disorder were admitted to our clinic, and ERF detected in 18 (5.5%) patients. There were 10 men and 8 women with a mean age of 54.7+/-11.9 years (range: 34 to 75 y). Metastases in the lung and liver were detected in 4 and 2 patients, respectively. Empyema was found in 3 of the ERF patients. Pneumonic infiltration was detected via radiologic evaluation in 7 (38.9%) of the 18 patients. Two patients did not accept any intervention. A feeding gastrostomy tube was placed in 2 other patients. Fluoroscopy-guided Ultraflex esophageal stent placement was applied to the remaining 14 patients. Eleven (78.6%) patients underwent stent placements during generalized anesthesia via rigid esophagoscopy, and the remaining 3 (21.4%)patients via flexible esophagoscopy with sedation. One of the patients who did not accept intervention died after 2 weeks, and the other died 6 weeks after admission. One of the patients who received a feeding gastrostomy tube died 17 weeks after admission, and the other was still alive after a month, when this article was written. Closure of the ERF was seen in all 14 patients who underwent palliative covered self-expandable metallic stent placement in the esophagus. No complications occurred in the stent-placed patients either during or after the procedure. Dyspeptic complaints and pain were treated successfully with medical therapy in 6 and 5 patients, respectively. Symptoms of aspiration disappeared after stent placement. No reopened fistulae were observed during follow-up. Thirteen of the 14 stent-replaced patients died during follow-up. The mean survival rate for these 13 patients was 11.2 weeks (range: 1 to 49 wk). The mean length of hospital stay after stent placement in the 14 patients was 3.7 days (1 to 15 d). Covered self-expandable metallic stent placement in malign ERF patients is a technically simple and safer method for fistula closure and seems to be the most effective method that is easily available.

Gastric Outlet Obstruction after Migration and Fracture of an Esophageal Stent: A Case Report

Purpose: The most common delayed complications of esophageal stent placement are recurrent dysphagia due to tumor ingrowth or overgrowth (5-22%), obstruction due to food bolus impaction (13-21%), stent migration (6-11%), and esophago-respiratory fistula (4-9%). Isolated cases of small bowel obstruction and perforation after stent migration have been reported, as have several cases of stent fracture. To the best of our knowledge, this is the first report of a migrated and fractured stent causing gastric outlet obstruction. An 80 year old man with a diagnosis of locally advanced esophageal adenocarcinoma involving the distal esophagus and gastric cardia had a palliative Wilson-Cook esophageal Z-stent with anti-reflux valve placed endoscopically without complication. After completion of palliative chemotherapy and radiation treatment, he had a repeat upper endoscopy that showed a patent stent and no tumor ingrowth or overgrowth. He denied dysphagia at that time. Six months later, he was admitted to the hospital with complaints of progressive pleuritic chest discomfort, shortness of breath, and non-bloody post-prandial emesis. Chest and abdominal radiographs as well as a CT scan showed migration of the esophageal stent into the stomach and new massive bilateral pleural effusions. Upper endoscopy was performed which showed a fractured esophageal stent in the antrum, likely crossing the pylorus into the bulb. The stent was not removed endoscopically. The patient elected for palliative measures alone, declining endoscopic or surgical removal of the stent. He was discharged to home hospice care.

A case of esophagorespiratory fistula successfully managed with a new technique for esophagoscopic closure

A case of esophagorespiratory fistula successfully managed with a new technique for esophagoscopic closure

The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer

Most patients with esophageal carcinoma present in the advanced stage die from tumor invasion and widespread metastases. Because radical regimens are not appropriate for the majority of patients, and their expected survivals are as short as to be measured by months, the main aim of therapy is palliation with minimum morbidity and mortality. Among the palliative modalities are surgery, external radiotherapy or brachytherapy, dilatation, laser, photodynamic therapy, bipolar electrocoagulation tumor probe, and chemical ablation. The placement of self-expandable metallic stents is another method that improves dysphagia for these patients. In this study, the aim was to evaluate retrospectively the effectiveness of metallic stents deployed because of inoperable malignant esophageal stenosis and esophagotracheal fistulas. The results of 170 patients with 202 stents administered because of inoperable malignant esophageal stenosis and esophagorespiratory fistula between January 2000 and October 2008 at the Ataturk University, Department of Thoracic Surgery, were investigated. Despite epidemiological and clinical data, information regarding relief of dysphagia and quality of life were also examined. One hundred seventy patients with stents were between 28 and 91 years old (mean age 63.7 years+/-11.4 years). Ninety-seven were male and 73 were female. Stent indications were advanced tumors with distant metastasis (82 cases, 48.2%), unresectable tumors (51 cases, 30%), patients who cannot tolerate surgery or chemoradiotherapy (18 cases, 10.5%), local recurrence after primary therapy (1 case, 0.5%), esophagorespiratory fistulas from tumor or therapy (14 cases, 8.2%), and refusal of surgery (4 cases, 2.3%). Dysphagia scores evaluated by a modified Takita's grading system improved from 3.4 before the procedure to 2.6 afterward. The overall complication rate without chest pain was 31.7% (occurring in 64 cases). Mean survival was 177.7 days+/-59.3 days (2-993 days). Quality-of-life scores (The European Organization of Research and Treatment of Cancer QLQ C30) improved from 73+/-10.3 (57-85) to 112+/-12.6 (90-125). In therapy of malignant esophageal obstructions, metallic stents provide a significant improvement in dysphagia and require less frequent re-intervention according to other methods of dysphagia palliation such as dilatation, laser, and photodynamic therapy, nearly completely relieve esophagotracheal fistulas and improve quality of life to an important degree.

What is the most effective palliation for esophagorespiratory fistulas?

What is the most effective palliation for esophagorespiratory fistulas?

Treatment of Postoperative Esophagorespiratory Fistulas with Dual Self‐Expanding Metal Stents

Fistulas between the esophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after esophageal resection. The traditional therapeutic approach is to deviate the proximal portion of the esophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. One hundred sixty-seven consecutive esophageal resections were reviewed to address the outcome of a stent-based therapeutic strategy in cases with esophagorespiratory fistulas. The patency of each anastomosis was checked only at the time of clinical suspicion of leakage but then radiology, endoscopy, and bronchoscopy were used together. Seven patients developed esophagorespiratory fistula. All of these fistulas were diagnosed more than 1 week after the operation. Two patients (27%) died due to the fistula. Four could be successfully treated but in two of these we were forced to change strategy and either perform a colonic interposition or externalize the esophagus. One of these patients subsequently developed total respiratory failure and required extracorporal membrane oxygenation (ECMO) to recover. When an esophagorespiratory fistula is diagnosed, an attempt to close the fistula tract by SEMS from both the esophageal and the respiratory side is a feasible treatment option. This strategy has to be prolonged and aggressive with a commitment to repeatedly change stents and modify sizes and designs. Thereby a majority of these patients can be managed conservatively with prospects of a successful outcome.

Infolding of Ultraflex self-expanding metal stent on insertion

Esophageal cancer is often diagnosed at an advanced stage, without curative options in 50 % – 60 % of cases. Of the major complications, the principal ones are luminal obstruction and esophagorespiratory fistulas [1].

Characteristics of Esophagorespiratory Fistulas Resulting from Esophageal Cancers: A Single‐Center Study on 243 Cases in a 20‐Year Period

Esophagorespiratory fistulas are serious complications of esophageal tumors. The main goal of this study was to reveal their characteristics. In the period between 1984 and 2004, 243 fistulas were diagnosed among the 1993 patients with esophageal cancer. Comparing the characteristic data of patients with and without fistula (demographics, symptoms, duration time of symptoms, morphologic features, histology, metastases, staging), multivariance analysis showed significant differences (P < 0.05). Patients with fistula were divided into two additional groups (I, n = 82; II, n = 161 cases) with cluster analysis. The difference between these two groups was also significant. It was possible to perform a palliative endoscopic intubation in 176 cases, while 62 patients could be treated only supportively. The average survival was 3.4 and 1.2 months, respectively. Fistula was a late complication of tumor in two thirds (66.3%) of the cases, while in 33.7% it was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia, and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival time was shorter (2.1 vs. 3.1 months). These tumors seem to be specific forms of esophageal cancers. For a better quality of life and longer survival time for these patients, there should be earlier diagnosis and endoscopic intubation as the best palliative treatment should be performed.

Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period

Esophagorespiratory fistulas developing from malignant tumors have serious complications by maintaining continuous airway contamination. The objective was to reveal the incidence, causes and characteristics of fistula formation and to examine the possibilities and efficiency of the treatment. In a single-center study between 1984 and 2004, the data of 2113 patients with tumorous esophageal stenosis were analyzed. Esophagorespiratory fistulas were detected in 264 cases (12.5%). Successful esophageal intubation, stent correction or replacement was performed in 188 cases, while there was one lethal complication. Twenty-seven patients had an intervention for nutritional support: 25 gastrostomies, 1 jejunostomy and 1 percutaneous endoscopic gastrostomy. The mean survival period of all patients was 2.8 months; patients with implanted endoprosthesis 3.4 months; with nutritional support 1.1 months and with only supportive therapy 1.3 months, respectively. The differences between the endoprosthesis implanted group and the other two groups were significant (p<0.001). By sealing the fistula, a successful endoscopic esophageal intubation ends the severe respiratory contamination and the inability to swallow, improving the quality of life and survival period. After the procedure, it is the malignant tumor and not the fistula that determines the future of the patient.

Successful treatment for a benign esophagorespiratory fistula with perioperative nutritional management and multistep esophageal bypass operation: a case report

A 49-year-old man was referred to our hospital for treatment of an esophagorespiratory fistula following 5-year airway stenting for stenosis of tracheal anastomosis. In consideration of the prior polysurgery and the patient’s poor general status and malnutrition, we selected multistep esophageal bypass combined with feeding enterostomy for nutritional support. Respiratory symptoms and pneumonia were rapidly improved by esophageal transection and decompression via a catheter esophagostomy. Nutritional status was also improved by enteral nutrition via a catheter gastrostomy. Four months after the esophageal transection, we conducted an esophageal bypass using an ileocolonic conduit because the right gastroepiploic artery had been used for omental reinforcement of tracheal anastomosis. The patient had no postoperative complications and was discharged 53 days after the bypass surgery. Multistep esophageal bypass including feeding enterostomy for perioperative nutritional management is a safe and useful alternative to direct closure for a critically ill patient with an esophagorespiratory fistula who is at high risk for operative mortality.

Expandable Nitinol Stent for Treatment of Malignant and Benign Esophagorespiratory Fistulas

Objective: Esophagorespiratory fistulas are complications of malignant esophageal tumours and bronchogenic cancer, and they are difficult to manage. The efficacy of polyurethane-covered nitinol stents for management of malignant and benign esophagorespiratory fistulas were analyzed prospectively. Patients and Methods: Twenty one patients (16 males-76%) with esophagorespiratory fistulas were treated with nitinol stents. The lesions were located in the proximal (n = 2), middle (n = 16) and distal (n = 3) esophagus.

Laparotomy enables retrograde dilatation and stent placement for malignant esophago-respiratory fistula

BackgroundMalignant esophageal stenosis with complete obstruction and esophagorespiratory fistula (ERF) is difficult to treat with standard endoscopic techniques.Case presentationWe report a patient in whom with local recurrence of esophageal carcinoma an esophagotracheal fistula occurred. Initially the patient had undergone esophageal resection with interposition of a gastric tube. Due to complete obstruction of the lumen by recurrent tumor conventional transoral stent placement failed. For retrograde dilatation a laparotomy was performed. Via a duodenal incision endoscopic access to the gastric tube was achieved. Using a guidewire the esophageal obstruction was traversed and dilated. Then it was possible to place an esophageal stent via an antegrade approach.ConclusionOpen surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.