Esophagomediastinal Fistula Research Articles

416. SUCCESSFUL TREATMENT OF ESOPHAGO-MEDIASTINAL FISTULA DUE TO ESOPHAGEAL CANCER WITH IMMUNE CHEMOPOINT INHIBITOR FOLLOWED BY ROBOTIC RADICAL ESOPHAGECTOMY

Abstract Background Esophagomediastinal fistula caused by intrathoracic esophageal cancer perforation poses significant challenges in treatment. We present a case of such a patient successfully treated by achieving complete resolution through surgical resection following chemotherapy with 5-FU, cisplatin, and pembrolizumab. Methods Clinical and surgical findings of the patient were reviewed through chart analysis. A 46-year-old male presented to the emergency room with fever and cough. Computed tomography (CT) indicated esophageal-mediastinal fistula due to mid-thoracic esophageal cancer and perforation. Endoscopic examination revealed a 5cm circumferential mass 20cm from the upper incisors, along with perforation. Biopsy confirmed poorly differentiated squamous cell carcinoma, with a PD-L1 CPS score of 80. The patient received multidisciplinary treatment involving chemotherapy followed by planned surgical intervention. Results First of all, the patient underwent peroral endoscopic gastrostomy for dietary intake. After 3-weeks interval three cycles of 5-FU (800mg/BSA, Day1-5), cisplatin (80mg/BSA, Day1), and pembrolizumab (200mg, Day1), complete resolution of the abscess cavity and significant reduction in esophageal cancer lesions were observed. Robotic transthoracic esophagectomy and Mckeown operation were performed, achieving complete resection of the esophagus including the primary lesion. Pathological examination revealed complete remission of the primary lesion and absence of metastatic nodes among the 51 dissected lymph nodes. After subsequent additional three cycles of anticancer-immunotherapy combined therapy were done, no signs of recurrence were found on CT scan performed 3 months post-surgery. Conclusion We report a case of successful treatment of a patient with thoracic esophageal cancer complicated by difficult-to-treat esophago-mediastinal fistula, managed effectively with concurrent chemotherapy and surgical intervention.

KC1036, a novel oral multi-kinase inhibitor, in patients with previously treated advanced esophageal squamous cell carcinoma (ESCC): Results from a multicenter, single-arm phase II trial.

e16011 Background: Therapeutic options for patients with previously treated advanced esophageal squamous cell carcinoma (ESCC) are limited. KC1036, a novel oral multi-kinase inhibitor of AXL, VEGFR2 and FLT3, has shown promising antitumor activity in preclinical and phase I studies. Here we report the preliminary outcomes from a phase II study, including the safety of KC1036 in patients with advanced gastrointestinal cancers, and the efficacy of KC1036 as second-line or later treatment in patients with advanced ESCC. Methods: In this multicenter, open label, single-arm phase II study, patients with advanced gastrointestinal cancers refractory to standard treatment were enrolled. For patients with advanced ESCC, those who had received standard first-line PD-1 blockade plus chemotherapy were eligible. KC1036 was administered orally at 60 mg QD, every 21 days as a cycle, until disease progression, death or intolerable toxicities. Primary endpoint was objective response rate (ORR) assessed by investigators per RECIST 1.1. Secondary endpoints included duration of response (DoR), progression-free survival (PFS), and safety. Results: Between June 8, 2022 and December 30, 2022, 58 patients were enrolled and received at least 1 dose of KC1036. The most common tumor type was ESCC (55.2%%, 32/58), followed by gastric cancer (13.8%, 8/58) and colorectal cancer (13.8%, 8/58). The median age was 63.5 (range 55.0-67.0) years. 29 patients (50.0%) had received prior treatment with PD-1 inhibitors and 46 patients (79.3%) had received platinum-containing chemotherapy. Lung metastasis and liver metastasis were observed at baseline in 39.7% (23/58) and 48.3% (28/58) of the patients, respectively. As of the data cut-off date (December 30, 2022), treatment-related adverse events (TRAEs) of any grade occurred in 50 (86.2%, 50/58) patients. 12 patients (20.7%, 12/58) reported grade 3 TRAEs, and the most common grade 3 TRAE was hypertension (5.2%, 3/58). Grade 4-5 TRAEs were reported in 2 patients, including one case of grade 4 esophagomediastinal fistula, and one case of death from unknown cause. 24 out of the 32 patients with advanced ESCC had at least one tumor response evaluation at data cut-off. Among them, 7 had partial response (PR), 13 had stable disease (SD), and 4 had progressive disease (PD) as best response. The ORR for ESCC patients was 29.2% (95% CI: 12.6%, 51.1%), and the DCR was 83.3% (95% CI: 62.6%, 95.3%). The median PFS was 4.2 months (95% CI, 2.20, 5.75), while the median DoR had not been reached. At data cut-off, 11 patients with ESCC were still receiving KC1036 treatment. Conclusions: KC1036 showed a manageable safety profile and promising anti-tumor activity in patients with previously treated advanced ESCC. This study is ongoing with further investigation of KC1036 in ESCC patients. Clinical trial information: NCT05260385 .

Diagnosis, prevention and treatment of post-operative rare complications after radical gastrectomy for gastric cancer

Radical gastrectomy for gastric cancer results in various post-operative complications, and the influencing factors are complicated. The diagnosis, treatment and prevention of common complications have been reported in many literatures. However, there are few reports on the prevention and treatment of rare complications. Rare complications after radical gastrectomy are often overlooked due to their low incidence. In addition, there are few guidelines and expert consensus regarding to the rare complications. Therefore, clinicians may lack experience in the diagnosis, treatment and prevention of rare complications after radical gastrectomy. Based on the literature review and the author's experience, this article systematically reviews seven rare complications after radical gastrectomy (duodenal stump fistula, pancreatic fistula, chyle leakage, esophagomediastinal fistula, internal hernia, gastroparesis, and intussusception). This article aims to provide a comprehensive reference for the diagnosis, treatment and prevention of rare complications after radical gastrectomy for gastric cancer patients.

Treatment mode and prognosis of esophageal perforation after radiotherapy in patients with esophageal carcinoma.

Retrospectively analyzed the esophageal carcinoma (EC) patients with esophageal perforation (EP) after radiotherapy to discuss the treatment and prognosis. Data of patients with EC who had EP after radiotherapy in Hebei Cancer Hospital were collected from 2001 to 2020 and retrospectively analyzed. All analyses were performed using SPSS Statistics for Windows, version 18. 0 (SPSS Inc., Chicago, Ill., USA). P values less than 0.05 were considered statistically significant. A total of 94 patients with EC were enrolled, among which 72 were males and 22 were females, with a median age of 62 (38-82) years. The tumor was located in the upper thoracic in 45 patients, middle thoracic in 45 patients, and lower thoracic in 4 patients. There were 30 cases of tracheoesophageal fistula (TEF) and 64 cases of esophagomediastinal fistula (EMF). All patients died within 11 months (median: two months) after EP. After EP, 48 patients were treated by tube feeding (include nasal feeding and gastrostomy), 26 patients by esophageal stenting, and 20 patients by fluid infusion therapy, and their one, three, and six months survival rates after EP were 81.3%, 31.3%, and 12.5% (P = 0.000). In the TEF group, the one, three, and six month survival rates after EP of tube feeding, esophageal stenting and fluid infusion groups were 88.2%, 17.6%, 11.8%; 45.5%, 27.3%, 0%; and 50.0%, 50.0%, 0% (P = 0.345). In the EMF group, the one, three, and six months survival rates after EP of this three groups were 77.4%, 38.7%, 12.9%; 26.7%, 20.0%, 6.7%; and 22.2%, 11.1%, 0% (P=0.002), respectively. Most patients with EP after radiotherapy died within six months, with low survival and poor prognosis. Tube feeding therapy can achieve relatively good survival, especially for patients with EMF. The survival of patients treated by tube feeding therapy is significantly better than the survival of those treated by other methods.

S2897 A Rare Case of a Esophagomediastinal Fistula Closed Endoscopically in a Young Patient With Tuberculosis and HIV

S2897 A Rare Case of a Esophagomediastinal Fistula Closed Endoscopically in a Young Patient With Tuberculosis and HIV

Fully covered self-expanding metallic stent placement or three-tube method for esophagomediastinal fistula: A STROBE-compliant article.

To determine the safety, feasibility and clinical outcomes of interventional methods for the management of esophagomediastinal fistula, and to investigate the effect of stent placement on fistula healing and the swallowing. Sixty consecutive patients with esophagomediastinal fistula were treated using interventional method and were retrospectively assessed. Patients received 3-tube but without covered stent placement were placed in group A, the remaining patients received covered stent placement with/without 3-tube method were placed in group B. Tubes and stents would be removed once fistula heals. Interventional procedures were technically successful all patients (100%). Esophageal stents and abscess drainage tubes were successfully removed from 14 patients. Three patients underwent stent removal during the perioperative period, resulting in a clinical success rate of 88.5% of 26 patients in group B. A total of 13 complications were found in all patients, including 5 major complications. Patients in group B showed a higher healing rate of abscess cavity and better dysphagia score than group A. During follow up, 17 patients in group A and 11 patients in group B were still alive. Interventional treatment is safe, feasible and efficacious for esophagomediastinal fistula; covered stent placement can promote fistula healing and improve swallowing.

Esophago-pericardial fistula after catheter ablation of atrial fibrillation: A review.

Much have been reported about esophago-left atrium fistula. However, esophago-mediastinal fistula, not reaching the left atrium, has not been studied as a different clinical entity, with different management. We review and discuss the literature of esophago-mediastinum fistula after catheter ablation for atrial fibrillation with emphasis on the following points: the timing of its occurrence after ablation; the mechanisms and localization of the fistula; and its natural history. We showed that esophageal stenting was associated with a better outcome in patients with esophagus-mediastinal fistula, introduced the concept of left atrial wall weakening during ablation, and suggest a possible role of contact force use in fistula formation.

Endoscopic management of an esophagomediastinal fistula arising from a cervical esophageal diverticulum after blunt chesttrauma.

Endoscopic management of an esophagomediastinal fistula arising from a cervical esophageal diverticulum after blunt chesttrauma.

A Case of Esophago-Mediastinal Fistula Treated by Esophageal Bypass

A Case of Esophago-Mediastinal Fistula Treated by Esophageal Bypass

Survival and prognostic factors of patients with esophageal fistula in advanced esophageal squamous cell carcinoma

The aim of the present study was to investigate the survival and prognostic factors of patients who were with advanced esophageal squamous cell carcinoma (ESCC) and developed an esophageal fistula. The data from 221 patients with advanced ESCC developed esophageal fistula from January 2008 to December 2017 at the Harbin Medical University Cancer Hospital was retrospectively analyzed. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by the Cox proportional hazard models. The median survival time after a diagnosis of the esophageal fistula was calculated using the Kaplan–Meier method. We found that the pathogens infected by patients are common bacteria in nosocomial infection. Besides, the incidence rate of esophagomediastinal fistula was the highest (54.2%) in the lower third of the esophagus. Kaplan–Meier analysis revealed a median survival time of 11.00 months and a median post-fistula survival time of 3.63 months in patients who developed esophageal fistula in advanced esophageal cancer. In the univariate analysis, gender, therapies for ESCC before the development of fistula, type of esophageal fistula, treatment of esophageal fistula and hemoglobin (Hb) level were the factors with significant prognostic value. Gender, type of esophageal fistula and Hb level were identified as independent prognostic factors in further multivariate analysis. In summary, our study demonstrated that several factors are significantly related to patients with esophageal fistula and should be concerned about in clinical practice.

“Esophagomediastinal fistula presenting as drug resistant tuberculosis”

Esophageal tuberculosis is one of the rarest forms of tuberculosis with higher incidence in immunocompromised cases. In majority of cases it is seen associated with esophagomediastinal and esophagotracheal fistulas. Diagnosis is established with the help of esophagoscopy followed by histopathology and microbiological analysis of biopsy sample. Treatment with antituberculous therapy alone is sufficient in majority of cases, however surgical management is mandatory in severe and non resolving cases. We thereby report an interesting case of esophagomediastinal fistula presenting as drug resistant tuberculosis with retroviral disease.

Tuberculous esophagomediastinal fistula with concomitant mediastinal bronchial artery aneurysm-acute upper gastrointestinal bleeding: A case report

BACKGROUNDEsophagomediastinal fistula is a very rare complication of tuberculosis in otherwise healthy adults, and mediastinal bronchial artery aneurysm is even rarer. In this case report, we describe a rare case of tuberculosis complication that presented with acute upper gastrointestinal (GI) bleeding. It also highlights the benefits of chest computed tomography (CT) as an excellent adjunct diagnostic tool to endoscopy and bronchoscopy and the role of trans-arterial embolization as a minimal invasive therapy alternative to surgery.CASE SUMMARYA 19-year-old medically free male patient presented with acute multiple episodes of hematemesis for 1 d. Upper GI endoscopy, bronchoscopy, and chest CT with IV contrast confirmed esophagomediastinal fistula with mediastinal bronchial artery aneurysm. After resuscitating patient with IV fluid and blood product transfusion, trans catheter embolization was performed for mediastinal bronchial artery aneurysm.CONCLUSIONWe successfully treated a patient with acute upper GI bleeding due to tuberculous esophagomediastinal fistula and mediastinal bronchial artery aneurysm using transcatheter coil embolization.

Barrett's esophagus in children: what is the evidence?

This study systematically reviewed etiology, prevalence, treatment and outcome of Barrett's esophagus (BE) in the pediatric population. PubMed® was searched for terms "Barrett's esophagus" and "children". End points were age of patients, etiology, association with other syndromes, treatment, incidence of carcinoma and outcome. This review was conducted according to the PRISMA guidelines. Data were collected, entered and analyzed into a Microsoft Excel® spreadsheet database. Search revealed 278 articles published between 1984 and 2017, of which 18 met the inclusion criteria. There were 130 patients for analysis witha mean age 10.6years (0.8-17.2years). BE was diagnosed in 80 patients with confirmed gastroesophageal reflux (GER) only; further20 patientswere neurologically impaired and had GER, 13after esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) repair with associated GER, 6 post-chemotherapy, 1 afterpost caustic burns, 1 after esophageal replacement with stomach, 1 afterpeptic esophageal stricture, 1 withsecretory diarrhea, 1 withFanconi anemia, 1tetralogy of Fallot, and 5 healthy children. Regarding treatment, 26 were on medical treatment only, 16 had surgeries combined with medical treatment, 80 patients underwent surgery only, 1 was on dietmanagement, 4 were on surveillance only and 2 were never treated for BE as death occurred because of associated conditions. Fundoplication was the most commonly performed surgery (82.2%). Adenocarcinoma was found in one 23-year-old patient. Mean follow-up was 3.45years (10months-13years) and long-term outcome showed recurrences in 8 and esophago-mediastinal fistula and proximal esophagus ulcer in 1. There were 7 lethal outcomes which were not directly associated with BE. Although BE is considered a premalignant condition; incidence of carcinoma in pediatric population is low. Long-term follow-up with endoscopies and biopsies seems to be advisable for BE evidence and malignant alterations.

Interesting case of spontaneously resolved dysphagia in a young female due to complicated esophageal tuberculosis

Mycobacterium tuberculosis can affect any organ of the body. Gastrointestinal tubercular involvement is fairly common. Esophageal tuberculosis though is uncommon. Esophageal tuberculosis accounts for only 0.3% of gastrointestinal tuberculosis. It presents with dysphagia, retrosternal pain, cough or constitutional symptoms. Complications like hemorrhage from the ulcer and development of fistulas like esophagomediastinal fistula is extremely uncommon. We report a case of a 27 years old female who presented with retrosternal pain, dysphagia and hematemesis. The patient had esophageal ulcer secondary to erosion of the esophagus by the subcarinal lymph nodes. Imaging was suggestive of esophagomediastinal fistula. Esophageal ulcer biopsy showed chronic tubercular infection. Culture from the esophageal biopsy confirmed the presence of tubercular bacilli. Patient responded to anti-tubercular therapy. Spontaneous dysphagia resolution prior to starting therapy was likely due to the rupture of the lymph node into the esophagus, which was compressing it initially. Esophageal tuberculosis presenting with hematemesis and fistula is extremely uncommon.

Closure of a Traumatic Esophagomediastinal Fistula in a Child by Endoscopic Fulguration and Fibrin Injection

Posttraumatic esophagomediastinal fistula is an uncommon clinical entity that warrants surgical awareness due to its life-threatening potential. Its management, especially in previously operated field, is controversial and several endoscopic methods are being proposed as alternatives. Ours is the first report of endoscopic fulguration and fibrin injection in successful closure of such fistula. A 9-year-old female sustained complete tracheoesophageal transection from a gunshot wound to the neck and underwent immediate primary repair. She presented nine months later with fevers and swelling over anterior neck. CT revealed air tracking posteriorly to the dorsal neck and inferiorly to the mediastinum. Considering difficulty of open surgical approach, endoscopic intervention was attempted. Posterior wall fistula was identified via microlaryngoscopy above the esophageal anastomosis. The fistula tract was de-epithelialized via a Bugbee fulgurating electrode and then sealed with fibrin glue. Consequent imaging studies demonstrated complete occlusion of the fistula. Posterior posttraumatic esophagomediastinal fistula presents a challenging scenario from a surgical standpoint, as it combines difficulty of safe approach, high rate of injury to surrounding structures, and significant postoperative recurrence rate. Endoscopic Bugbee fulguration and fibrin glue injection are a safe and effective alternative to the traditional approach.

Multidrug-Resistant Tuberculous Mediastinal Lymphadenitis, with an Esophagomediastinal Fistula, Mimicking an Esophageal Submucosal Tumor.

Mediastinal tuberculous lymphadenitis rarely mimics esophageal submucosal tumor, particularly in the case of multidrug-resistant tuberculosis (MDR-TB). Herein, we report the case of a 61-year-old woman who visited a local hospital complaining of odynophagia. An initial esophagogastroduodenoscopy revealed an esophageal submucosal tumor, and subsequent chest computed tomography showed subcarinal lymphadenopathy with an esophagomediastinal fistula. The patient was then referred to Samsung Medical Center, and a second esophagogastroduodenoscopy showed deep central ulceration, as well as a suspicious fistula in the esophageal submucosal tumor-like lesion. A biopsy examination of the ulcerative lesion confirmed focal inflammation only. Next, an endobronchial, ultrasound-guided lymph node biopsy was performed, and TB was confirmed. The patient initially began a course of isoniazid, rifampicin, ethambutol, and pyrazinamide. However, after a drug sensitivity test, she was diagnosed with MDR-TB, and second-line anti-TB medications were prescribed. She recovered well subsequently.

A Case of Nontuberculous Mycobacterium Infection Complicated by an Esophagomediastinal Fistula in a Human Immunodeficiency Virus Patient

An esophagomediastinal fistula is rare complication of nontuberculous mycobacterium infection. Here, we report the case of a patient with advanced acquired immunodeficiency syndrome who presented with a fever, cough, and dyspnea, and was eventually diagnosed with nontuberculous mycobacterium infection. Computed tomography revealed multiple lymphadenopathy with an esophagomediastinal fistula. The patient was treated with anti-mycobacterial medications and endoscopic fistula closure. (Korean J Med 2015;88:612-616)

811 Management of Endoscopic Perforation With Abdominal Exploration and Full-Thickness Sutured Closure

created to achieve durable response. Multiple sessions are required in certain patients. All procedures were done under general anesthesia. Results: Six patients (4F, 2M) presented for closure of chronic enteric fistulas.This included: 1. esophagomediastinal (n=1), 2. gastrocutaneous (n=3), 3. bronchial-esophageal (n=2). The patient with esophagomediastinal fistula (5 cm size) was repaired with an enteral stent deployment and fixation of the proximal end of the stent to the esophagus. The three patients with gastrocutaneous fistulas (n=3) all were as a result of bariatric surgery, all closed successfully with combination of interrupted and running sutures in two separate layers. One of these patients developed a dehiscence at 10 days postprocedure and was closed after a second suturing session. Finally the two patients with bronchial-esophageal fistulas (n=2) were closed successfully but dehiscence of the sutures required repeat suturing sessions (3 and 4 sessions respectively) prior to final closure. No complications were observed. Patients resumed oral diets within 7-14 days following closure. Contrast studies were done in all patients to ensure complete closure within 48 hours of the procedure. Conclusions: Enteric fistulas may present a therapeutic challenge. Surgical options may have significant morbidity and mortality. Endoscopic suturing can successfully close enteric fistulas with low

Successful closure of unusual tuberculous esophagomediastinal fistula with endoscopic clips

A 41-year-old man, on tuberculostatic treatment for three months for disseminated tuberculosis, developed a tuberculous esophagomediastinal fistula, which was successfully closed with endoscopic clips. Use of endoscopic clips in esophageal perforations and closure of fistulas following surgical complications has been described, but to our knowledge there are no previous reported cases of tuberculous esophagomediastinal fistulas managed with clipping. In this case, endoscopic clips associated with tuberculostatic treatment were crucial allowing fistula closure in a symptomatic patient.

A Bronchoesophageal Fistula that Developed Shortly after the Initiation of Antituberculous Chemotherapy

A 26-year-old man visited our clinic because of a persistent cough. Although his chest roentgenography showed no abnormalities, a sputum culture revealed a positive result for Mycobacterium tuberculosis. Computed tomography (CT) prior to antituberculous chemotherapy demonstrated an esophagomediastinal fistula with subcarinal lymphadenopathy. One week after the treatment, he complained of a severe cough exacerbated by swallowing liquid. The development of a bronchoesophageal fistula (BEF) was suggested by esophagoscopy, and was confirmed by CT and bronchoscopy. The present case was unique because the process of BEF development could be followed by CT, and the BEF developed in an immunocompetent patient with relatively mild pulmonary tuberculosis.