Treatment Of Esophageal Fistula Research Articles

Retrospective analysis of 10 cases with esophageal fistula after anterior surgery for cervical spine fracture

ObjectiveThis study aims to discuss the appropriate treatment of esophageal fistula following anterior surgery for cervical spine fracture. MethodsClinical data of patients with cervical spine fracture treated at our research center from January 2000 to December 2019 were screened. Data of patients with esophageal fistula were included, and the causes of injury, diagnosis, and treatment were retrospectively analyzed. ResultsA total of 3578 patients with cervical spine fracture were screened, among whom there were 10 cases (0.28 %) of esophageal fistula. 60 % of the cases were early-onset and all were caused by intraoperative electric knife injury. The positive rate of early endoscopy was only 25 %, while routine radiography showed a positive rate of 33.3 % after three attempts. Among the six patients with early-onset esophageal fistula, three underwent sternocleidomastoid flap transfer and two underwent primary suture, all achieving successful healing. In the four cases of late-onset esophageal fistula, two patients received implant removal, debridement, incision lavage, and sternocleidomastoid muscle flap transfer three weeks later. One patient received implant removal, debridement, vacuum sealing drainage, followed by sternocleidomastoid muscle pedicle transfer muscle flap plus lavage two weeks later and achieved complete recovery. All patients gargled alternately with metronidazole and chlorhexidine gargle after surgery. ConclusionThe occurrence of esophageal fistula is associated with surgical procedures, esophageal injury, and implant compression. Esophagography and endoscopy are the primary diagnostic methods, while incision exploration after ingestion of food mixed with methylene serves as a supplementary approach. Recommended treatments include alternating metronidazole and chlorhexidine gargles, esophageal rest, repair of the fistula, muscle flap packing, lavage and drainage, nutritional support, and removal of internal fixation if necessary. Post-surgery administration of antibiotics should continue until three consecutive lavage cultures yield negative results.

The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review.

We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022. The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure. Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.

Use of the endoscopic vacuum therapy technique for the treatment of esophageal fistulas: an integrative review and clinical case series study

Esophageal fistula is a rare disease with a mortality rate of up to 31% of cases and with multifactorial causes. The most common etiologies of esophageal perforation are associated with iatrogenic, foreign body ingestion, as well as cases of lesions of neoplastic origin. Consisting of an innovative therapy with efficiency not yet evaluated in clinical studies, the present study sought to report a series of cases of patients with esophageal fistulas undergoing treatment with endoscopic vacuum therapy (VTE) assisted by the service team of a tertiary public hospital. from the state of Ceará in order to contribute with evidence that reinforces the role of VTE in the closure of esophageal perforations of different etiologies. In addition, in order to contextualize the importance of the cases presented, we carried out an integrative review in order to list the main clinical findings on the use of VTE available in the world scientific literature. There was a need for continuous development of new clinical studies that seek to improve and validate the use of VTE for the safe and effective treatment of esophageal fistulas, emphasizing that treatment with VTE can maximize the therapeutic response, bringing a greater and better clinical patient satisfaction.

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.

Emulsified stromal vascular fraction tissue grafting: a new frontier in the treatment of esophageal fistulas

A 54-year-old woman was admitted in an acute life-threatening condition with right pleural empyema in Boerhaave syndrome during chemotherapy. After right pleural surgical toilette, a Micro-Tech fistula occluding stent (A 30, B24-mm, Micro-Tech, Nanjing, China) was placed and fixed with Apollo overstitch during gastroscopy to occlude the perforation of the distal part of the esophagus. After resolution of the sepsis, the patient was discharged with normal oral intake. Two months later, stent removal was attempted, but the patient’s clinical condition dramatically worsened, and a gastrografin esophagogram showed persistence of a 2-cm esophagopleural fistula (A).

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.

Cytomegalovirus-Associated Esophagopulmonary Fistula in an AIDS Patient Successfully Treated with Esophageal Stenting

Introduction: A 46-year-old man with AIDS and poor antiretroviral adherence presented with a 12-day history of chest pain, dyspnea, cough, and fever. Examination revealed tachycardia, cachexia, and thrush. One month prior, CD4 count was 9/mm3 and HIV viral load was 57,647 copies/mL. Chest CT noted a dominant cavitary mass in the right upper lobe, several smaller pulmonary cavitations, and proximal esophageal dilatation. Treatment for bacterial pneumonia and candidiasis was started. Initial infectious studies, including acid-fast sputum smears, were negative. Despite 7 days of broad-spectrum antibiotics, his cough worsened, serial chest imaging noted disease progression, and sputum culture grew MRSA and commensal bacteria. Three weeks into his course, he developed dysphagia and odynophagia. Serum PCR for Cytomegalovirus (CMV) was 701 copies/mL. EGD noted a cratered 5-cm longitudinal ulcer in the proximal esophagus (Figure 1A) and a 1-mm fistulous opening within the ulcer (Figure 1B). Barium esophagram revealed a communication between the proximal esophagus and right hemithorax (Figure 1C). Chest CT demonstrated tracking of barium from the esophagus into the dominant pulmonary cavity (Figure 1D). These findings were consistent with the diagnosis of an esophagopulmonary fistula. On repeat EGD, biopsies of the ulcer were obtained, followed by placement of a 12-cm fully-covered metal stent across the fistula. Pathology showed esophageal squamous epithelium, inflamed reactive stroma, and acutely inflamed columnar respiratory-type mucosa with scattered CMV-positive cells, confirmed on immunohistochemistry (Figure 1E). The patient received valgancyclovir for 21 days and the stent was removed 35 days after placement with resolution of the ulcer. Repeat barium esophagram showed no structural abnormalities. We present the first reported case of a CMV-associated esophagopulmonary fistula successfully treated with antiviral therapy and a fully-covered metal esophageal stent. Esophagorespiratory fistulas are rare and usually associated with malignancy or post-operative complications. Use of fully-covered metal stents has been described in the treatment of esophageal fistulas and leaks with variable success.Figure 1

Pressure Necrosis for the Removal of Embedded Self Expanding Esophageal Stents: A Rare Treatment for a Common Problem

Purpose: Covered self expandable metallic stents (SEMS) have traditionally been used for the treatment of malignant esophageal obstruction; however, recently they have been employed in the treatment of esophageal fistulas. Partially covered SEMS have been shown to be safe and effective and offer the benefit of decreased migration. However, safe removal is difficult due to tissue hyperplasia at the uncovered ends of the stent leading to its embedment into the esophageal wall. We report a case demonstrating successful removal of a partially covered SEMS by pressure necrosis created from placing a fully covered polyflex stent via a “stent in stent” method. A 64-year-old male was referred to our service after development of an esophageal perforation resulting in pneumonia and pleural effusion secondary to a TEE performed during cardioversion for paroxysmal atrial fibrillation. This arrhythmia occurred after the patient had a gastric sleeve procedure for morbid obesity. The patient had a partially covered SEMS placed with the proximal end above the gastroesophageal junction at 39cm from the incisors. The partially covered stent was initially chosen to help create a tissue seal at both ends of the stent to promote healing and to prevent migration. Tissue overgrowth was seen at the proximal end of the stent, but no tissue hyperplasia was seen at the distal end. The distal end of the stent extended down into the proximal gastric body, and the area of the perforation still appeared to be well covered. A 12 cm long fully covered polyflex stent with a central diameter of 18mm flaring out to 23mm at the ends was then successfully deployed under fluoroscopic guidance inside of the previously placed stent with the proximal end overlapping the proximal end of the previously placed stent by 3cm. We then confirmed endoscopically that the polyflex stent was completely covering the area of tissue overgrowth at the proximal end of the stent. Three weeks later, the patient went for repeat EGD, and the polyflex stent was successfully removed with alligator forceps revealing that nearly all of the tissue overgrowth had resolved at the proximal end of the stent from prior exam due to effective pressure necrosis. We initially were unable to remove the partially covered stent by gripping the proximal end with the alligator forceps, and we eventually had to grip the distal end and employ an eversion technique under fluoroscopic guidance with gentle traction to successfully remove the stent. The stent-in-stent technique is safe and effective for the removal of partially covered SEMS that are embedded into the esophageal wall. We recommend further larger prospective trials to analyze this method for the removal of SEMS.

Esophagopleural fistula treated endoscopically with argon beam electrocoagulation and clips

Fistulas of the esophagus can extend into the pleural cavity, mediastinum, or bronchial tree and can be caused by trauma and bacterial infections, in particular mycobacterial disease. However, they most frequently occur as a result of malignancies of the esophagus, lungs, or mediastinum, either as a primary complication or after treatment of these cancers with radiotherapy or chemotherapy. Under these circumstances, palliation can be obtained by esophageal stenting, preferably with a self-expandable coated stent. 1 Morgan PRA Ellul JPM Denton ERE Glynos M Mason RC Adam A. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology. 1997; 204: 527-532 PubMed Google Scholar , 2 Raijman I Lynch P. Coated expandable esophageal stents in the treatment of digestive-respiratory fistulas. Am J Gastroenterol. 1997; 92: 2188-2191 PubMed Google Scholar , 3 Spivak H Katariya K Lo AY Harvey JC. Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis. J Surg Oncol. 1996; 63: 65-70 Crossref PubMed Scopus (21) Google Scholar Although clinically successful in more than 95% of patients, 1 Morgan PRA Ellul JPM Denton ERE Glynos M Mason RC Adam A. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology. 1997; 204: 527-532 PubMed Google Scholar , 4 Bethge N Sommer A Vakil N. Treatment of esophageal fistulas with a new polyurethane-covered, self-expanding mesh stent: a prospective study. Am J Gastroenterol. 1995; 90: 2143-2146 PubMed Google Scholar the use of these stents has disadvantages. Esophageal perforations and lethal hemorrhages occur in 2% to 5% of cases. 5 Swain CP Gong F Murfitt J. Difficulties with placement of esophageal metal stents and development and testing of new delivery method and covered stents. Gastrointest Endosc. 1995; 41 ([abstract]): 358 Abstract Full Text PDF Google Scholar , 6 May A Hahn E Ell C. Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. J Clin Gastroenterol. 1996; 22: 261-266 Crossref PubMed Scopus (107) Google Scholar , 7 Kozarek RA Ball TJ Brandabur JJ Patterson DJ Low D Hill L et al. Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems. Gastrointest Endosc. 1996; 43: 204-208 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Stent migration and food impaction occur frequently, necessitating endoscopic reintervention in more than 10% to 15% of patients within 3 months. 6 May A Hahn E Ell C. Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. J Clin Gastroenterol. 1996; 22: 261-266 Crossref PubMed Scopus (107) Google Scholar Other therapeutic options, in selected cases, are the use of tissue glue, with success in about 50% of patients, 8 Hirao M Shimada M Kaneko T Mizunoya S Okagawa K. Two cases of esophageal fistula, in which a fibrin glue preparation was effective. J Jpn Assoc Thor Surg. 1994; 42: 2144-2149 Google Scholar , 9 Cellier C Landi B Faye A Wind P Frileux P Cugnenc P-H et al. Upper gastrointestinal tract fistulae: endoscopic obliteration with fibrin sealant. Gastrointest Endosc. 1996; 4: 731-733 Abstract Full Text Full Text PDF Scopus (59) Google Scholar or surgery, which has high morbidity (30%) and mortality (10%) rates even in specialized centers. 3 Spivak H Katariya K Lo AY Harvey JC. Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis. J Surg Oncol. 1996; 63: 65-70 Crossref PubMed Scopus (21) Google Scholar , 10 Fernando HC Benfield JR. Surgical management and treatment of esophageal fistula. Surg Clin North Am. 1996; 76: 1123-1135 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar

SURGICAL MANAGEMENT AND TREATMENT OF ESOPHAGEAL FISTULA

Esophageal fistula may involve the respiratory or cardiovascular system. Fistulas involving the respiratory system which originate from esophageal cancers are the most common. Diagnosis is best made with barium esophagogram. ERF of any cause usually leads to repetitive contamination of the respiratory tract, resulting in sepsis and death of the patient if untreated. In the case of MERF, whether from esophageal or lung cancer, only palliative treatment is usually possible. Better results, including cure, may be expected when a MERF is caused by lymphoma. Curative operation with closure of the fistula is usually possible for BERF if the fistula is identified and treated before irreversible damage has been done by infection, sepsis, and malnutrition. Esophagocardiovascular fistulas occur infrequently in comparison with ERF. These may involve the aorta, usually as a result of a thoracic aneurysm. Rarely one may encounter esophageal fistula to the pericardium or heart. Few survivors have been reported, but successful management is possible if early diagnosis is made and prompt surgical management is undertaken.