Malignant Tracheoesophageal Fistula Research Articles

Comparison of Malignant and Non-malignant Acquired Tracheoesophageal Fistulae Management Strategies and Outcomes

Aim: To compare the malignant and non-malignant acquired tracheoesophageal fistulae management strategies. Study design: Prospective study Place and duration of study: Bolan Medical College Teaching Hospital, Quetta from 1st January 2022 to 31st December 2022. Methodology: Sixty patients suffering from tracheoesophageal fistulae were enrolled. The patients were then divided into two groups where depending upon convenient sampling the first group was named as malignant while second was non-malignant group. The underlying etiology of each patient was recorded and assessments of clinical conditions were made through imaging and endoscopic techniques. The preoperative, intraoperative and stenting management strategies were applied on the enrolled cases. Single, double stenting was based on case to case. Results: The mean age of the cases with benign tracheoesophageal fistula was 10.5±1.2 years while those having malignant tracheoesophageal fistula was 51.2±6.5 years. There were total 20 cases of tracheoesophageal fistula with nonmalignant diagnosis while 40 cases with malignant tracheoesophageal fistula. Within the primary outcomes of the cases the preoperative mortality was higher in non-malignant cases than malignant while morbidity was much higher in the malignant cases with 35% in that presenting fistula recurrence. Practical Implication: Malignancy appeared to be the main cause of TEF in patients and their survival chances are also less. Conclusion: Stenting is best managing strategy in patients with improved survival rate malignant as well as non-malignant cases. Keywords: Malignancy, Fistula, Esophagus, Ventilator, Stenting

Central airway stenting in oncology

Introduction. Malignant central airway obstruction and malignant tracheoesophageal fistula in the context of tumor development are potentially life-threatening conditions which usually require immediate intervention. Airway stenting is one of the safest and most effective methods of airway patency restoration in patients with malignant obstruction of the central airways and restoration of continuity in patients with malignant tracheoesophageal fistula.Aim. To evaluate the significance of self-expandable metal stents in palliative treatment of patients with malignant central airway obstruction and malignant tracheoesophageal fistula.Materials and methods. Between 2017 and 2021 at the N. N. Blokhin National Medical Research Center of Oncology, 55 patients were observed and treated and underwent trachea stenting per the results of bronchoscopy in combination with esophagogastroduodenoscopy. The 1st group included 25 patients with malignant tracheoesophageal fistulas, the 2nd group included 30 patients with malignant central airway obstruction.Results. In the 1st group, stenting was successful in 25 (100 %) cases which allowed to adequately seal the fistula. Stent migration was observed in 1 (4 %) patient with tracheoesophageal fistula in the context of stenosing cancer of the thoracic esophagus. In the 2nd group, stenting was successful in 30 (100 %) cases. Stent migration was not observed in this patient group. In both groups, there were no complications after stent implantation. Installation of tracheal stent allowed to improve patients’ quality of life and provide a possibility for successful special treatment through low-trauma manipulation.Conclusion. According to the obtained data, endoscopic trachea stenting is the most important method of palliative treatment of tumor-related trachea lesions with development of tracheoesophageal fistulas, malignant central airway obstructions and associated sub- and decompensated pulmonary insufficiency.

Efficacy of stent placement in treatment of malignant tracheoesophageal fistula and relevant factors of fistula closure

Objective: To investigate the efficacy of stent placement in the treatment of malignant tracheoesophageal fistula (MTEF) and the factors affecting the closure of the fistula. Methods: Clinical, pathological, laboratory, and imaging data of 288 patients with MTEF admitted to Zhongda Hospital, Southeast University from 2015 to 2021were retrospectively analyzed. Among them, there were 208 males; the age was (63.6±10.5) years. A total of 94 patients received conservative treatment (conservative group), and 194 in the stent group (170 cases with esophageal stents and 24 cases with tracheal stents). Patients were followed-up at 2 weeks, 1 month, 3 months, and 6 months to evaluate the effect of stent implantation. Multivariable logistic regression was used to analyze factors affecting fistula closure. Results: Age, fistula size, leukocyte count before treatment, and fistula location were significantly different between the conservative group and the stent group (P<0.05). The Karnofsky functional status (KPS) score before treatment in the conservative group was lower than the stent group, (45.1±1.0) vs (51.8±0.7) scores, respectively (P<0.001). After 2 weeks and 1 month of treatment, improvement in KPS scores was significantly better in the stent group than in the conservative group (P<0.05). At 1 month, the pulmonary infection rate in the stent group was 33.5% (58/173), significantly lower than that in the conservative group [77.0% (47/61); P<0.001]. Among the 288 patients, the fistula was closed in 196 patients and unclosed in 92 patients. Fistula size (OR=3.429, 95%CI: 1.623-7.829, P=0.001), leukocyte count before treatment (OR=1.160, 95%CI: 1.027-1.317, P=0.018), KPS score before treatment (OR=0.898, 95%CI: 0.848-0.945, P<0.001) and the treatment method (conservative treatment as reference, esophageal stent OR=0.010, 95%CI: 0.004-0.030, P<0.001; tracheal stent OR=0.003, 95%CI: 0.000-0.042, P<0.001) were factors affecting fistula closure. In the 170 patients in the esophageal stent group, early complications (≤24 h) occurred in 71 patients, and late (>24 h) complications occurred in 11 patients. While in the 24 patients in the tracheal stent group, 9 had early complications and 2 had late complications. Conclusions: Stent placement is an effective treatment for MTEF compared to conservative treatment. Stent treatment, small fistula size, low pre-treatment leukocyte count, and high pre-treatment KPS score are beneficial to fistula closure.

THE NONCOMPLIANT PATIENT WITH THE BROKEN STENT

THE NONCOMPLIANT PATIENT WITH THE BROKEN STENT

Case report: Surgical repair of a large tracheo-esophageal fistula in a patient with post-transplant esophageal lymphoproliferative disorder

Introduction and importanceThe management of large malignant tracheo-esophageal fistulas (TEF) is not standardized. Herein, we report a case with a malignant TEF associated with esophageal post-transplant lymphoproliferative disorder (PTLD) for whom we successfully performed a surgical repair. This contributes to the knowledge on how to treat large acquired malignant TEFs.Case presentationA 69-year old male presented with a one-week history of fever, productive cough and bilateral coarse crackles. In addition, he described a weight loss of 10 kg during the past three months. The patient's history included a kidney transplantation twenty years ago. Esophagogastroduodenoscopy with a biopsy of the esophagus was performed nine days before. Histopathology showed a PTLD of diffuse large B-cell lymphoma subtype. Subsequent diagnostics revealed a progressive TEF (approx. 2.0 × 1.5 cm) 3.0 cm above the carina. PET-CT scan showed an esophagus with slight tracer uptake in the middle third (approx. 11.5 cm length, SUV max 7.4). After decision against stenting, transthoracic subtotal esophagectomy with closure of the tracheal mouth of the fistula by a pedicled flap was performed. PTLD was treated with prednisone and rituximab. Tumor progression (brain metastasis) led to death 95 days after surgery.Clinical discussionThe treatment of a malignant TEF is complex and personalized while both the consequences of the esophago-tracheal connection and those of the underlying responsible diagnosis have to be considered concurrently. In this case, we considered surgery as the best treatment option due to a relatively good prognosis of the underlying diagnosis (PTLD) and a large fistula. Esophageal or dual stenting, the treatment of choice for small malignant TEF, would have been associated with a high risk of failure due to the wide trachea, extensively dilated esophagus, proximal location and large diameter of the fistula.ConclusionSurgery can be considered for patients with a large acquired malignant TEF and positive long-term prognosis of the underlying diagnosis. Due to the complexity of TEF management, immediate pre-operative multidisciplinary discussion is advised.

Self-Expandable Metal Stent in the Management of Malignant Airway Disorders.

BackgroundSelf-expanding metallic stent (SEMS) is a palliative therapy for patients with malignant central airway obstruction (CAO) or tracheoesophageal fistula (TEF). Despite this, many patients experience death shortly after SEMS placement.AimsWe aimed to investigate the effect of SEMS on the palliative treatment between malignant CAO and malignant TEF patients and investigate the associated prognostic factors of the 3-month survival.MethodsWe performed a single-center, retrospective study of malignant CAO or TEF patients receiving SEMS placement. Clinical data were collected using the standardized data abstraction forms. Data were analyzed using SPSS 22.0. A two-sided P-value <0.05 was statistically significant.Results106 malignant patients (82 CAO and 24 TEF) receiving SEMS placement were included. The body mass index (BMI), hemoglobin levels, and albumin levels in the malignant TEF group were lower than in the malignant CAO group (all P < 0.05). The procalcitonin levels, C-reactive protein levels, and the proportion of inflammatory lesions were higher in the malignant TEF group than in the malignant CAO group (all P < 0.05). The proportion of symptomatic improvement after the SEMS placement was 97.6% in the malignant CAO group, whereas 50.0% in the malignant TEF group, with a significant difference (P = 0.000). Three months after SEMS placement, the survival rate at was 67.0%, significantly lower in the malignant TEF group than in the malignant CAO group (45.8% vs. 73.2%, P = 0.013). Multivariate analysis revealed that BMI [odds ratio (OR) = 1.841, 95% certificated interval (CI) (1.155-2.935), P = 0.010] and neutrophil percentage [OR = 0.936, 95% CI (0.883–0.993), P = 0.027] were the independent risk factors for patients who survived three months after SEMS placement.ConclusionsWe observed symptom improvement in malignant CAO and TEF patients after SEMS placement. The survival rate in malignant TEF patients after SEMS placement was low, probably due to aspiration pneumonitis and malnutrition. Therefore, we recommend more aggressive treatment modalities in patients with malignant TEF, such as strong antibiotics, nutrition support, and strategic ventilation. More studies are needed to investigate the prognostic factors in patients with malignant airway disorders receiving SEMS placement.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. 5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.

An alternative method for tracheal stent deployment in malignant tracheo-oesophageal fistula

An alternative method for tracheal stent deployment in malignant tracheo-oesophageal fistula

Transtracheal Cyanoacrylate Glue Injection for the Management of Malignant Tracheoesophageal Fistula

Introduction: Malignant tracheoesophageal fistula (TEF) is a devastating complication of esophageal cancer, lung cancer or other carcinoma associated with high mortality, short survival, and poor quality of life. Covered metallic stents placement either in trachea/esophagus or both are used for the palliative treatment. Other endoscopic modalities rarely attempted for benign and malignant TEF includes use of over the scope clip, transesophageal glue injection, electrocautery and laser. Case description: A 56-year-old man presented with complain of intractable cough on swallowing for last 3 months. He had completed a course of chemo radiotherapy for carcinoma of middle one third of the oesophagus four months back. The upper gastrointestinal endoscopy showed a stricture with superficial ulceration at 23 cm from lower incisor in the oesophagus. A small (˜ 4 mm diameter) fistula was noted just above the stricture. Application of over-the-scope clip was failed. A hydrophilic guide wire (0.032” inches diameter) was placed through the ERCP cannula into the fistula. Bronchoscopy revealed the presence of guidewire coming out from a fistulous tract in the posterior wall of the trachea above the tracheal bifurcation. The guide wire was grasped with a biopsy forceps. The guide wire was removed along with the scope from the mouth. The fluoroscopic image showed a curved course (length of the fistula was about 2.5 cm) of the guide wire. After assessment of the fistula by the track of the guidewire, two routes of glue injection were considered, Trans-tracheal and Trans-esophageal. Transesophageal route was considered risky due to an expected spillage of the glue within the trachea. Hence, the option of transtracheal glue injection was selected. The cannula and the scope were reintroduced through the trachea. The presence of the markers on the cannula were used to assess the depth of insertion of cannula within the fistula and to plan the site of injection of the glue.1 ml of cyanoacrylate glue was injected while pulling the cannula out. 1 ml of distilled water was injected while pulling out the rest of the cannula to the tip of the fistula. After one hour, the patient started swallowing liquids without any cough. Patient has remained asymptomatic till now.Figure: Arrow showing the location of fistula.Figure: Hydrophilic wire inserted into the fistula.Conclusion: Transtracheal glue placement may be safer than transoesophageal glue placement. This appears to be first report of transtracheal glue injection of malignant TEF. Watch the video: https://goo.gl/46aJ9F

Recurrent and congenital tracheoesophageal fistula in adults.

Recurrent congenital tracheoesophageal fistula (TEF) is well documented in infancy but may also present later in life. This study reviews our experience with the clinical presentation, diagnosis and management of 5 recurrent and 2 primary congenital tracheoesophageal fistulas (TEF) in adult patients. There are no literature series of late recurrence of TEF (repaired in childhood and recurring in adulthood) and relatively few reported cases of initial adult presentation of TEF. In this series, we aim to provide the first large series description of late recurrence of congenital TEF following repair in infancy or childhood. We also present management considerations for this unique group of patients. We performed a computer-based search of the adult thoracic surgery departmental operative database at our institution from 2002 to 2014. Patients with iatrogenic TEF or malignant TEF were excluded. Seven patients are included in our series. Five patients (71%) had recurrent congenital TEF and 2 (29%) had initial diagnosis of congenital TEF. All presented with severe coughing symptoms, and most (86%) had a history of recurrent aspiration pneumonia. Repair technique was dictated by the location of the TEF and the specific tracheoesophageal pathology. Four patients underwent repair via cervical approach with or without a tracheal resection. Three patients with distal recurrence underwent repair via right thoracotomy with partial oesophagectomy for significant tissue compromise and cervical reconstruction. Patients were followed for at least 1 year. All 7 patients experienced full resolution of symptoms. One patient required postoperative placement of a retrievable tracheal stent for tracheomalacia. There were no mortalities. Adult presentation of congenital TEF is a rare but recognizable clinical entity. Recurrent TEF in adulthood is a possible late complication of TEF repair performed in childhood that has not previously been described. Adult patients experiencing symptoms of cough and recurrent aspiration pneumonia should be evaluated for congenital TEF. Surgical repair of congenital TEF in the adult is feasible and effective with acceptable morbidity.

Transtracheal cyanoacrylate glue injection for the management of malignant tracheoesophageal fistula

Background:Malignant tracheoesophageal fistula (TEF) is a devastating complication of esophageal cancer, lung cancer, or other carcinoma associated with high mortality, short survival, and poor quality of life. Covered metallic stents placement either in trachea/esophagus or both are used for the palliative treatment. Other endoscopic modalities rarely attempted for benign and malignant TEF include use of over the scope clip, transesophageal glue injection, electrocautery, and laser.Case Description:A 56-year-old man presented with complaint of intractable cough on swallowing for last 3 months. He had completed a course of chemo-radiotherapy for carcinoma of middle one-third of the esophagus 4 months back. The upper gastrointestinal endoscopy showed a stricture with superficial ulceration at 23 cm from lower incisor in the esophagus. A small (~4 mm diameter) fistula was noted just above the stricture. Application of over-the-scope clip was failed. A hydrophilic guide wire (0.032″ diameter) was placed through the ERCP cannula into the fistula. Bronchoscopy revealed the presence of guidewire coming out from a fistulous tract in the posterior wall of the trachea above the tracheal bifurcation. The guide wire was grasped with a biopsy forceps. The guidewire was removed along with the scope from the mouth. The fluoroscopic image showed a curved course (length of the fistula was about 2.5 cm) of the guidewire. After assessment of the fistula by the track of the guidewire, two routes of glue injection were considered, transtracheal and transesophageal. Transesophageal route was considered risky due to an expected spillage of the glue within the trachea. Hence, the option of transtracheal glue injection was selected. The cannula and the scope were reintroduced through the trachea. The presence of the markers on the cannula was used to assess the depth of insertion of cannula within the fistula and to plan the site of injection of the glue. 1 mL of cyanoacrylate glue was injected while pulling the cannula out. 1 mL of distilled water was injected while pulling out the rest of the cannula to the tip of the fistula. After one hour, the patient started swallowing liquids without any cough. The patient has remained asymptomatic till now.Conclusion:Transtracheal glue placement may be safer than transesophageal glue placement. This appears to be the first report of transtracheal glue injection of malignant TEF.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE), endorsed by the European Society for Radiotherapy and Oncology (ESTRO), the European Society of Digestive Endoscopy (ESDO), and the European Society for Clinical Nutrition and Metabolism (ESPEN). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations for malignant disease 1 ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliative treatment of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass (strong recommendation, high quality evidence). 2 For patients with longer life expectancy, ESGE recommends brachytherapy as a valid alternative or in addition to stenting in esophageal cancer patients with malignant dysphagia. Brachytherapy may provide a survival advantage and possibly a better quality of life compared to SEMS placement alone. (Strong recommendation, high quality evidence.) 3 ESGE recommends esophageal SEMS placement as the preferred treatment for sealing malignant tracheoesophageal or bronchoesophageal fistula (strong recommendation, low quality evidence). 4 ESGE does not recommend the use of concurrent external radiotherapy and esophageal stent treatment. SEMS placement is also not recommended as a bridge to surgery or prior to preoperative chemoradiotherapy. It is associated with a high incidence of adverse events and alternative satisfactory options such as placement of a feeding tube are available. (Strong recommendation, low quality evidence.) Main recommendations for benign disease 1 ESGE recommends against the use of self-expandable stents (SEMSs) as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and costs (strong recommendation, low quality evidence). 2 ESGE suggests consideration of temporary placement of SEMSs as therapy for refractory benign esophageal strictures (weak recommendation, moderate evidence). Stents should usually be removed at a maximum of 3 months (strong recommendation, weak quality evidence). 3 ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures, because of their lack of embedment and ease of removability (weak recommendation, low quality evidence). 4 For the removal of partially covered esophageal SEMSs that are embedded, ESGE recommends the stent-in-stent technique (strong recommendation, low quality evidence). 5 ESGE recommends that temporary stent placement can be considered for treating esophageal leaks, fistulas, and perforations. The optimal stenting duration remains unclear and should be individualized. (Strong recommendation, low quality evidence.) 6 ESGE recommends placement of a SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive esophageal variceal bleeding (strong recommendation, moderate quality evidence).

Tracheoesophageal fistula managed with tracheal stent through flexible bronchoscopy without fluoroscopy

Inoperable malignant tracheoesophageal fistula (TEF) is characterised by an extremely poor prognosis. Tracheal or double (tracheal-esophageal) stenting through rigid bronchoscopy has been suggested as a valuable therapeutic option. We report on a patient with a large TEF successfully sealed by deployment of a self-expandable stent through flexible bronchoscopy (FB) without fluoroscopy. Dramatically improved health status permitted him to undergo radiation, attaining further clinical improvement. Four months after stent placement no sequelae were observed. During the fifth month a new fistula developed distally to the stent finally leading to death from septic complication. Palliative management of inoperable malignant TEF by tracheal stent placement through FB without fluoroscopy, is feasible, safe and rewarding leading to important clinical improvement.

Airway Covered Metallic Stent Based on Different Fistula Location and Size in Malignant Tracheoesophageal Fistula

Malignant tracheoesophageal fistula (MTEF) is a devastating complication of esophageal cancer, lung cancer or other carcinoma with a shorter life-span and poor life quality. The aim of this study was to assess the effect of airway stent insertion on MTEF patients. A total of 63 MTEF patients were included, 12 patients with lung cancer and 46 patients with esophageal cancers. Eight zones were proposed to classify various fistula locations. Airway stents were selected based on the various zones and fistula size. Airway stents were successfully inserted in all patients, and both airway and esophageal stents in 8 patients. Most fistula were located in locations II (18/63, 28.6%), III (22/63, 34.9%), then VII (9/63, 14.3%). The stents included 10 (15.9%) I shaped, 8 (12.7%) L shaped and 45 (71.4%) Y shaped. Different stents were placed based on different locations and sizes of fistulas. Overall, mean survival time was 163 days (2-270 days). Most symptoms relieved after stent insertion. Mean Karnofsky score jumped from 43.0 ± 10.7 before stent placement to 66.7 ± 10.8 after stent insertion (P = 0.000). Complete closure was achieved in 45 patients (71.4%), and incomplete closure and leakage were found in 18 patients. Airway stent insertion provides an effective approach to improve symptoms and quality of life. The choice of stent based on different fistula location and size may be a reasonable way in clinical practice.

Study progress of malignant tracheoesophageal fistula

Malignant tracheoesophageal fistula (MTEF) is pathological communication between the respiratory tracts such as the trachea or bronchia and the esophagus because of malignant tumor dissemination through them.Radiography is an important adjunctive technology in the diagnosis of MTEF,and the location and size of fistula often need the further diagnosis of bronchoscopy and esophagoscopy.The patients are often with an unfavourable prognosis once developed MTEF,and are treated usually with the aim of symptom palliation and life quality improvement.The individual treatment includes esophageal stenting,esophageal exclusion and esophagus bypass,fistula exclusion and repair,radiotherapy and others effective therapy according to the patients condition.These therapies will prolong the life span and improve the life quality of patients.MTEF is not absolute contraindication for chemoradiotherapy.Despite its acute toxicity,this concurrent chemoradiothe rapy protocol appears feasible and effective at closing esophageal malignant fistula,especially in patients in a good general condition and without metastasis. Key words: Tracheoesophageal fistula; Stents; Surgical procedures,operative; Radiotherapy; Drug therapy

Yikes… spikes! Exposed tracheal cartilaginous spikes at EGD from malignant tracheoesophageal fistula

A 67-year-old woman with squamous cell carcinoma of the lung that had been diagnosed 6 months earlier, and recent biopsy-proven metastasis to her right hip, presented with 3 months of progressive dysphagia and involuntary weight loss. Physical examination revealed temporal wasting, clear lung fields, a normal abdomen, and brown stool without occult blood. The results of all laboratory studies were normal except for a hemoglobin of 8.7 g/dL, microcytic indices, and a serum albumin level of 3.4 g/dL.

Esophageal Stenting and Radiotherapy: A Multimodal Approach for the Palliation of Symptomatic Malignant Dysphagia

Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia. We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement. We placed stents in 45 patients for esophageal stricture from esophageal cancer (n = 30; 66.7 %), malignant TEF (n = 8; 17.7 %), and esophageal compression from airway, mediastinal, or metastatic malignancies (n = 7; 15.6 %). Twenty patients (44.4 %) had no RT; 25 patients had RT before stent placement (n = 16; 35.6 %), RT after stent placement (n = 8; 17.8 %), or both (n = 1; 2.2 %). Median follow-up was 30 days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9 % of all patients, with no differences noted between groups (p = 0.99). The 30-day mortality was 15.6 %. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38 days). Esophageal stent placement with RT is a safe approach for malignant dysphagia.

Su1339 Learning Curve for Placement of Esophageal Stents in Malignant Tracheoesophageal Fistula in an Inanimate Biological Model

Su1339 Learning Curve for Placement of Esophageal Stents in Malignant Tracheoesophageal Fistula in an Inanimate Biological Model

Palliative Tracheal and Esophageal Double Stenting for Tracheoesophageal Fistula

Purpose: Malignant tracheoesophageal fistula is a relatively rare condition that results in serious morbidity and mortality due to recurrent aspiration, sepsis, and death. We describe herein the use of combined tracheal and esophageal stenting for palliative care. A 58 y.o. veteran with a history of COPD and NSC lung cancer, (stage IIIB of the left lung) with a lingular cavitary lesion was evaluated for increased dyspnea and inability to handle secretions. CT scan revealed tracheoesophageal fistula connecting the left main bronchus and mid-esophagus. Following a detailed discussion with the patient, a combined tracheal and esophageal stenting to correct the defect was planned. The patient first underwent successful placement of a 13 mm Boston Scientific Dynamic Y™ stent into the trachea and main bronchi. Unfortunately, the Y stent was not long enough to extend past the fistulous opening in the left main bronchus by 0.5 cm as would be ideal. The patient recovered from the procedure uneventfully. Two days later he underwent successful placement of a Wilson-Cook Evolution™ 20-25-10 stent into the esophagus which completely sealed the 3 cm defect. The patient tolerated the second procedure well with significant improvement in his symptoms. This case highlights the palliative role combined tracheal and esophageal stenting can have in patients with malignant tracheoesophageal fistula. Careful selection and meticulous technique are crucial to the success of the procedure and go a long way towards improving patients' quality of life.Figure

Acute Superior Vena Cava Occlusion After Stenting of Tracheoesophageal Fistula

Acute development of superior vena cava syndrome is unusual. This report describes a patient who suddenly presented with a superior vena cava obstruction after esophageal and tracheal stenting for a malignant tracheoesophageal fistula. Stenting of the superior vena cava rapidly alleviated the obstruction and resulted in resolution of symptoms.