Management Of Esophageal Fistulas Research Articles

Diagnosis and Management of Esophageal Fistulas After Lung Transplantation: A Case Series.

Lung transplantations are highly complex procedures, often conducted in frail patients. Through the addition of immunosuppressants, healing can be compromised, primarily leading to the development of bronchopleural fistulas. Although esophageal fistulas (EFs) after lung transplantation remain rare, they are associated with significant morbidity. We aimed to investigate the clinical presentation, diagnostic approaches, and treatment strategies of EF after lung transplantation. All patients who developed EF after lung transplantation at the University Hospitals Leuven between January 2019 and March 2022 were retrospectively reviewed and the clinical presentations, diagnostic approaches, and treatment strategies were summarized. Among 212 lung transplantation patients, 5 patients (2.4%) developed EF. Three patients were male and median age was 39 y (range, 34-63). Intraoperative circulatory support was required in 3 patients, with 2 needing continued support postoperatively. Bipolar energy devices were consistently used for mediastinal hemostasis. All EFs were right-sided. Median time to diagnosis was 28 d (range, 12-48) and 80% of EFs presented as recurrent respiratory infections or empyema. Diagnosis was made through computed tomography (n = 3) or esophagogastroscopy (n = 2). Surgical repair with muscle flap covering achieved an 80% success rate. All patients achieved complete resolution, with only 1 patient experiencing a fatal outcome during a complicated EF-related recovery. Although EF after lung transplantation remains rare, vigilance is crucial, particularly in cases of right-sided intrathoracic infection. Moreover, caution must be exercised when applying thermal energy in the mediastinal area to prevent EF development and mitigate the risk of major morbidity. Timely diagnosis and surgical intervention can yield favorable outcomes.

Another Use for Padlock Clip.

The novel over-the-scope Padlock clip was reported to assist in the management of esophageal fistulas, refractory gastrointestinal (GI) bleeding, and GI defects closure. A little is known about the management of non-lifting colon polyps with fibrosis secondary to prior intervention. Resection could be challenging given prior intervention. The tools used to remove such polyps are different between institutions.In this study, we describe our experience with Padlock clip in removing non-lifting colon polyp.

Covered metallic stent for the treatment of malignant esophageal fistula combined with stricture

BackgroundEsophageal fistula and stricture is rare but life-threatening complication for esophageal cancer. The management of esophageal fistula and stricture remains challenging. We aimed to determine the safety, feasibility and efficacy of covered metallic stent and three tubes placement for the management of esophageal fistula and stricture.MethodsBetween May 2012 and March 2018, all patients with esophageal fistula and stricture were treated using three tubes or covered metallic stent placement. Patients in group A received covered stents and three tubes placement. Patients in group B only received three tubes placement. Continue abscess drainage and nutritional support was performed after procedure. Three tubes or esophageal stents were removed once esophageal fistula heals. The related medical records were retrospectively assessed.ResultsThirty-seven consecutive patients with esophageal fistula and stricture were enrolled, including 26 patients in group A and 11 patients in group B. Stent placement procedure was technically successful in 25 patients (96.2%). A total of 42 covered stents were inserted. Seventeen esophageal stents were successfully removed from 10 patients. The median retention duration was 3.3 months and 3.4 months for stent and abscess drainage tubes, respectively. One perioperative death due to massive hemorrhage was observed 21 days after stent placement. The abscess cavity was decreased or disappeared in 17 cases and 4 cases in group A and group B, respectively. During follow up, patients in group A still showed a significant better condition of normal diet than that in group B (p < 0.05). Fourteen patients died of cancer recurrence, 3 patients died of massive digestive bleeding and 2 patients died of severe pulmonary infection. The median survivals were 14.8 months and 13.2 months for group A and group B, respectively.ConclusionsCovered metallic stent placement is safe, feasible and efficacious for treatment of esophageal fistula and stricture, with a better condition of normal diet than patients only received three tubes placement.

344 Multi-Modality Endotherapy of Esophagopleural Fistula (EPF) Using a Novel External Stent Anchoring Mechanism

INTRODUCTION: Esophagopleural fistula (EPF) is a condition associated with high morbidity and mortality. The management of patients with chronic, recurrent, nonmalignant EPF remains controversial and challenging. CASE DESCRIPTION/METHODS: A 61-year-old man with a history of esophagopleural fistula (EPF) in diagnosed in 2013 treated with covered esophageal stent and subsequent decortication with resolution of symptoms and esophageal leak who presented to the hospital with sepsis. Chest CT revealed a fistula between the distal esophagus and right pleural space with large right-sided hydro-pneumothorax with resulting near complete collapse of the right lower and middle lobes. Chest tube was placed with external wound suction by luminal vacuum sponge. GI were consulted for endoscopic management. Upper Endoscopy revealed a 20 mm fistula in the lower third of the esophagus. The decision was made to close the fistula with endoscopic suturing and placement of esophageal stent. Three days following the procedure the esophageal stent migrated distally. This was repositioned endoscopically and anchored with repeat Overstitch of endoscopic clips. This again was displaced after 4 days. Due to the patient poor conditional status and the absence of offers for nonsurgical options, an alternative method of anchoring of esophageal was explored in the form of an external anchoring. This was done by loading the stent and suturing the proximal end at 12 and 6 o’clock, the stent was loaded back and then deployed in the patient esophagus under flurouscopic guidance. Then, the previously placed anchoring suture material was located and brought out of the mouth using a forceps. The sutures then were rerouted into each nostril using a nasal gastric tube. Then these anchoring sutures were loosely tied at/around the nasal septum using a soft rubber tube to protect the nasal septum. The procedure was technically successful and the patients was discharged from the hospital three days later. After one month, the patient’s nutritional status improved, and he underwent definitive thoracic surgery at an outside facility. DISCUSSION: Self-expandable metal stents are increasingly used in the management of esophageal fistulas but their efficacy is limited by high migration rate. Previously described methods to prevent stent migration include the use of endoscopic clips and endoscopic suturing. We describe external anchoring technique to maintain the esophageal stent in position in a case when endoscopic suturing failed. Watch the video: http://bit.ly/2YiObuS

Causes, Treatment and Prevention of Esophageal Fistulas in Anterior Cervical Spine Surgery

To evaluate the causes, treatment and prevention of esophageal fistulas after anterior cervical spine surgery. Between January 2004 and December 2011, 5 of 2348 patients who underwent anterior cervical surgery in our hospital developed esophageal fistulas (three male and two female patients, average age 34 years). Their diagnoses were cervical injuries (three), cervical spondylosis (one) and cervical tuberculosis (one). Their esophageal fistulas were treated by debridement and exploratory surgery, primary suturing of the perforation and/or sternocleidomastoid myoplasty. If conservative treatment failed or esophageal fistula recurred, plate removal was offered. Postoperative treatment included esophageal rest, enteral nutrition, wound drainage, and antibiotics. Methylene blue was used to evaluate results. An esophageal fistula was discovered during anterior cervical surgery in one patient and primary suturing performed. In four patients, fistulas were diagnosed after anterior cervical decompression and fusion. In one of these, only debridement and exploratory surgery were required. In another, a perforation was sutured during debridement and exploratory surgery. In the third, internal fixation was removed because of failure of prolonged conservative treatment. In the fourth, the esophageal fistula recurred repeatedly; he required removal of the hardware and reinforcement with a sternocleidomastoid muscle flap. At 6-48 months follow-up, all patients were in good condition, symptom free, and without cervical instability or infectious spondylitis. Successful management of esophageal fistula after anterior cervical spinal surgery depends on primary closure of the perforation with or without muscle flaps, surgical drainage, esophageal rest and nutritional support, and removal of hardware if necessary. Prevention consists of careful surgery and gentle tissue handling.

Management of esophageal fistula caused by anterior cervical spine surgery

Objective To evaluate cause,treatment and prevention of esophageal fistula caused by anterior cervical spine surgery.Methods Between January 2004 and December 2011,2348 patients underwent anterior cervical spine surgery.Among them,5 patients suffered from esophageal fistula owing to operation,including 3 males and 2 females,with an average age of 34 years (range,14 to 48 years).The diagnosis of these patients included 3 cases of cervi(c)al injury,1 case of cervical spondylosis and 1 case of cervical tuberculosis.There was 1 patient whose esophageal injury was founded during the surgery,and that was directly repaired.For another 4 patients,esophageal fistulas were founded after operation; one case underwent debridement and orificium fistulae repair; one case only underwent debridement; one case underwent debridement and second-stage removal of hardware; and one case underwent debridement and second-stage removal of hardware and esophageal repair with sternocleidomastoid flap.Postoperative treatment included esophageal rest,enteral nutrition,wound drainage,and antibiotic administration.Methylene blue was used to evaluate status of orificium fistulae.Results All patients with esophageal fistula were cured 9 to 61 weeks after treatment,and oral intake was achieved.They were followed up for 6-48 months.There was no recurrence of esophageal fistula,cervical instability and infectious spondylitis in any ease.All patients were satisfied with swallowing function and outcome of cervical spine diseases.The Frankel grade was improved averagely one grade in patients with cervical injury,and the JOA score was improved from preoperative 9 points to postoperative 15 points in patients with cervical spondylosis.Conclusion Successful management of esophageal fistula caused by anterior cervical spinal surgery depends on primary closure of the perforation with or without muscle flaps,surgical drainage,esophageal rest and nutrition support,and removal of hardware if necessary.Prevention consists of the careful operation and gentle tissue handling. Key words: Cervical vertebrae; Esophageal fistula; Postoperative complications