The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas.

OBJECTIVES: Esophageal strictures and esophagorespiratory fistulas are complications of malignant esophageal tumors, which are difficult to manage. The efficacy of self-expanding metal stents (SEMS) for palliation of malignant esophageal strictures and fistulas was investigated prospectively. METHODS: Forty-three SEMS were inserted in 41 patients with malignant esophageal stricture or fistula. Our series included 32 men and nine women, of whom median age was 61.4 years. Twenty nine stents were inserted for stricture, ten for esophago-tracheal fistula, and four esophago-pleural fistula. Stents were inserted endoscopically under fluoroscopic control. RESULTS: SEMS implantation was technically successful in 40 of 41 patients. A second stenting was needed in two patients. Median dysphagia score improved from 3.4 to 1.3. The covered SEMS was succesful in completely sealing 85.7% of the fistulas. Complication occurred in 11 (26.8%) patients. Especially in the case of tumor stenoses in the distal esophagus, complication rate was higher (44%). In total six patients (14.6%) died after stent placement during early postoperative period. Procedure-related mortality was 4.8% (2/41). CONCLUSIONS: We conclude that treatment of malignant esophageal obstructions, including esophagorespiratory fistulas, with SEMS is an alternative palliative procedure. Furthermore SEMS implantation seems more safe in the case of tumor stenoses locating in the middle esophagus.     

Successful management of multiple esophagorespiratory fistulas using two types of stent: Report of a case

We herein describe a 41-year-old man with esophageal cancer who developed three esophagorespiratory fistulas (ERFs) that were successfully treated using one esophageal and three airway stents. A self-expandable metallic stent (SEMS) was initially inserted into the esophagus to close an ERF in the right bronchus. However, two new ERFs developed in the trachea and the left main bronchus 3 months later because of pressure necrosis and penetration of the esophageal SEMS. These secondary ERFs were subsequently closed using two silicone stents, together with one SEMS in the airway. This experience suggests that appropriate stenting can control multiple and large ERFs.     

Treatment of oncogenic emergencies in esophageal disease

Common oncogenic emergent conditions of the esophagus are esophageal fistula with malignancy and peptic ulcer, perforation by a foreign body, and rupture (Boerhaave's syndrome) and bleeding with malignancy. The current standard of palliative therapy for patients with malignant tracheoesophageal fistula is endoscopic replacement using covered self-expandable metallic stents in the esophagus and/or trachea. We successfully treated two patients with esophageal bleeding caused by malignant ulceration. To prevent the formation of an aortoesophageal fistula, a covered self-expandable metallic stent was inserted into the esophagus and aorta. Insertion of covered self-expandable metallic stents in patients with esophageal malignancies significantly improves dysphagia, seals fistulas/perforations and ulcerations, and is associated with acceptable morbidity and mortality rates. Spontaneous esophageal rupture, also known as Boerhaave's syndrome, is a rare condition. Primary repair is appropriate for ruptures diagnosed early. Many are diagnosed late and T-tube drainage may be the simplest way to manage this difficult condition in this situation.     

Acquired benign esophagorespiratory fistula: report of 16 consecutive cases

Sixteen cases of acquired benign esophagorespiratory fistula were treated in a 20-year period. A delay in diagnosis was usual, and most patients were first seen with a pulmonary infection already developed. Contrast esophageal x-ray studies established the diagnosis in all patients. There were seven esophagotracheal and nine esophagobronchial fistulas. A fistula between the esophageal diverticulum and a bronchus considered to be of inflammatory origin developed in 7 patients. A fistula as the consequence of trauma developed in 9 patients, and these fistulas were situated at a higher level of the respiratory tree. All patients underwent surgical treatment; in 12 it was definitive, and in 4 temporary gastrostomy was performed to improve nutrition before definite repair. The definitive repair consisted of eventual diverticulectomy, division of the fistula, and suture of both esophageal and respiratory defects. Two patients required esophageal resection and later reconstruction with colon interposition. One patient died, creating an operative mortality of 8.3% in the definitive-repair group. The remaining 11 patients had a gratifying long-term result. There were two deaths in the gastrostomy group due to an extremely poor condition of patients and debilitating pulmonary infection. Early diagnosis of this rare condition is necessary if severe pulmonary complications are to be avoided. Early direct repair gives excellent results.     

Acquired benign bronchoesophageal fistulas in the adult

In a twenty-year period we have seen 7 patients with acquired nonmalignant bronchoesophageal fistulas at the Vanderbilt University Affiliated Hospitals. There were 5 men and 2 women ranging from 24 to 82 years old. Six patients were seen initially with a history of pulmonary inflammatory disease with cough and fever or with an abnormal chest roentgenogram. One patient had a traumatic fistula following blunt chest trauma. Six of the patients were treated surgically with no operative mortality. Five were repaired through a right-sided thoracotomy with division of the fistulous tract and closure of the bronchus and esophagus. One patient required esophageal resection and later reconstruction for permanent fistula closure. The remaining patient was diagnosed at bronchoscopy and was not treated surgically because of supervening complications following an extensive abdominal operation. Once the diagnosis was established, operative management resulted in complete closure of the fistulas, with no mortality and no late recurrences in these patients.     

Esophageal bypass using a gastric tube and a cardiostomy for malignant esophagorespiratory fistula

Esophageal bypass with a gastric tube and a cardiostomy is a method recently devised for malignant esophagorespiratory fistula. This method separates completely the alimentary and respiratory tracts. Four patients underwent these procedures. No operative deaths occurred, nor was there any anastomotic leakage or disruption of the excluded esophagus. The average survival time was 7 months. However, all patients were allowed to consume food orally up to the last moment of life. This bypass procedure is simple and safe to perform, and is thus a feasible treatment choice for patients with such fistulas.     

Perforating Barrett's ulcer resulting in a life-threatening esophagobronchial fistula

Perforating benign ulcer is a very rare complication of Barrett's esophagus. This report presents the management of a patient with a Barrett's ulcer that penetrated into the left mainstem bronchus resulting in a life-threatening bronchial esophageal fistula. This rare complication was successfully managed by using a staged surgical approach, which combined the principles used for treating benign esophagorespiratory fistulas and perforating Barrett's ulcers.     

Rectovaginal fistulography: a technique for the identification of recurrent elusive fistulas

Introduction and hypothesis  The purpose of this study is to review our experience with a technique for diagnosing small rectovaginal fistulas that occasionally permit passage of air or mucus. Methods  During an in-office visit suspicious areas of the vagina were probed with a cone-tip catheter and injected with a contrast dye to visualize the suspected fistula tract communicating to the rectum under fluoroscopic guidance. The fistulous tracts were further isolated using a flexi-tip glide wire. Results  Five out of nine patients were found to have fistulas not diagnosed by other means. Three patients had recurrent rectovaginal fistula after a vaginal delivery, one patient was identified with a high rectovaginal fistula due to diverticular disease, and one patient had a rectovaginal fistula due to prior hemorrhoidectomy. One patient had a negative test, and the fistula that was diagnosed intraoperatively was due to underlying Crohn’s disease. Conclusion  Direct fistulography is a useful technique to visualize otherwise elusive symptomatic rectovaginal fistula tracts.     

Removal of esophageal expandable metal stents

BACKGROUND: Expandable metallic stents (EMS) have seen wide application in patients with malignant stricture and fistulas. They have not seen wide application for benign disease because of concern over acute complications and long-term sequelae. METHODS: Between June 1999 and October 2000, six patients with EMS in place for malignant stricture (n = 3), benign stricture (n = 1), anastomotic leak (n = 1) and benign esophagorespiratory fistula (n = 1) had their stents endoscopically removed. Removal was performed secondarily to the following complications: secondary stricture (n = 1), epidural abscess (n = 1), diskitis (n = 1), resolution of fistula (n = 2), and resolution of anastomotic leak (n = 1). RESULTS: Four patients had one EMS: Ultraflex (n = 3) and Z-stent (n = 1). In two patients, two stents (Ultraflex and Z-stent) were retrieved simultaneously. No procedurally related complications occurred. Two patients with esophageal cancer required additional stents. All three patients with benign fistula and stricture recovered uneventfully. CONCLUSIONS: The safe removal of current brands of EMS may facilitate the wider application of these devices to include selective patients with benign disease.     

Pessimism concerning palliative bypass procedures for established malignant esophagorespiratory fistulas: a report of 18 patients

Eighteen patients with established malignant esophagorespiratory fistulas due to primary esophageal cancer were managed by substernal gastric bypass and isolation of the cancerous esophageal segment. Seven fistulas were esophagotracheal and 11 were esophagobronchial. Ten patients died in the hospital between two days and six weeks after operation. Eight patients left the hospital, surviving an average of 3 1/2 months, but 2 patients lived 5 and 7 months, respectively. Unrelenting respiratory infection and clinical inanition caused 7 hospital deaths in patients reestablished on oral alimentation with their fistulas disconnected. Anastomotic leaks occurred in 5 patients; three of these leaks closed. In the other 2 patients, cervicomediastinal sepsis and bilateral pneumonia with respiratory failure caused death. One patient died of anoxic cardiac arrest 48 hours postoperatively. Fifteen of the 18 patients resumed oral alimentation, but the overall results of palliative surgical therapy achieved in this series were not observably worthwhile for the majority.     

Self-expandable metal stents to treat gastric leaks.

OBJECTIVES: Anastomotic leak is a major complication after gastric bypass (GBP) surgery, and it usually necessitates reoperation and is associated with long-term recovery and death. We present our experience with the use of self-expandable metal stents (SEMS) to treat this complication. METHODS: Seventeen patients (14 males and 3 females, mean body mass index of 43.7 kg/m(2)) with gastro-jejunal leak after GBP underwent covered SEMS placement 1 to 3 weeks after surgery: 8 laparoscopic, 5 open, and 4 revisional procedures. All patients who underwent laparoscopic and revisional procedures had abdominal drains placed at surgery. No drains were placed in the open cases. Five patients required surgery to drain an abdominal abscess. RESULTS: Tolerance for oral feeding was achieved between 2 and 3 days after SEMS placement. One patient persisted with a minimal leak for 2 weeks. To date, all stents have been removed endoscopically 3.2 +/- 1.2 months after placement. Four patients needed a second session to complete removal of the uncovered top of the stent. Two esophageal mucosal tears occurred; both were managed conservatively. Sixteen patients had a totally sealed leak. One remained with a gastro-gastric fistula. One stent spontaneously migrated to the splenic flexure and was removed colonoscopically. CONCLUSIONS: SEMS placement for gastro-jejunal leaks is a safe therapeutic option.     

Double stenting for esophageal and tracheobronchial stenoses

Background. We examined the complications and outcomes of placing stents for both esophageal and tracheobronchial stenoses.

Methods. We placed stents for both esophageal and tracheobronchial stenoses in 8 patients (7 with esophageal cancer and 1 with lung cancer). Covered or noncovered metallic stents were used for the esophageal stenoses, except in 1 patient treated with a silicone stent. Silicone stents were used for the tracheobronchial stenoses. The grades of esophageal and tracheobronchial stenoses were scored.

Results. All patients experienced improvement of grades of both dysphagia and respiratory symptoms after stent therapy. The complications were: (1) 2 patients suffered respiratory distress after placement of the esophageal stent because of compression of the trachea by the stent; and (2) 3 patients developed new esophagotracheobronchial fistulae, and 2 patients had recurring fistula symptoms because of growth of preexisting fistulae after the stent placement, which were caused by pressure from the 2 stents. Despite the fistulae, the 5 patients treated with covered metallic stents did not complain of fistula symptoms, but 2 patients treated with noncovered metallic or silicone stents did complain.

Conclusions. For patients with both esophageal and tracheobronchial stenoses, a stent should be introduced into the tracheobronchus first. Because placement of stents in both the esophagus and tracheobronchus has a high risk of enlargement of the fistula, a covered metallic stent is preferable for esophageal cancer involving the tracheobronchus.     

Acquired nonmalignant tracheoesophageal fistula

Acquired tracheoesophageal fistula (TEF) caused by cuffed tracheal tubes, surgical trauma, and blunt injuries is an unusual and serious problem. Several differing approaches to management have been proposed. We have repaired such fistulas in 20 patients; 14 of them were related to tracheal intubation, three to blunt trauma, two followed anterior cervical spine fusions, and one resulted from a foreign body. Fistula closure on ventilator-dependent patients was usually delayed until they were weaned from respiratory support. Four patients had esophageal diversion before repair of their fistulas. There was sufficient tracheal damage to require resection and end-to-end anastomosis in 13 patients. The esophageal defect was closed directly in 16 patients, and end-to-end reconstruction of the esophagus was accomplished in four. There were two deaths, and one fistula recurrence required reoperation. These results support our recommendations to delay fistula closure in most ventilator patients, to use esophageal diversion selectively, to employ tracheal resection when there is evidence of extensive damage, and to directly repair the esophagus.     

Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks

Background  Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks. Methods  All esophageal stent placement procedures (174 procedures for 157 patients) at the authors’ unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave’s syndrome (n = 4), or an anastomotic leakage (n = 2). Results  The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease. Conclusions  Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.     

The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery

BackgroundThe use of endoluminal stents has been proposed for the management of fistulas and anastomotic strictures after bariatric surgery. The objective of our study was to determine the success of endoscopically placed, self-expandable metal stents (SEMS) in bariatric patients specifically with either chronic persistent anastomotic or staple line leaks/fistulas or chronic, persistent anastomotic strictures.MethodsWe treated 21 patients including 5 with chronic staple line leaks/fistulas (4 from the gastric sleeve after biliopancreatic diversion with duodenal switch [BPD/DS] and 1 after removal of an eroding laparoscopic adjustable gastric band) and 16 with chronic anastomotic strictures (15 at the gastrojejunostomy after Roux-en-Y gastric bypass and 1 at the duodenoileal anastomosis after BPD/DS). Patients with early leaks or anastomotic strictures were excluded.ResultsAll but one of these patients had been referred to our institution after chronic treatment elsewhere was unsuccessful with prior stent placement for fistulas or multiple endoscopic dilations for strictures. Their bariatric operations had been performed a mean of 386 days beforehand. Stent placement was performed successfully in all patients without complications but was successful in only 4 of 21 patients (19%)—2 with chronic fistulas and 2 with chronic anastomotic strictures. Stent migration occurred in 10 patients (47%); the migrated stents were removed/replaced endoscopically in 7 patients but required elective operative removal in 3 with concomitant correction of the leak, fistula, or anastomotic stricture; none were operated emergently.ConclusionOnly 4 of 21 patients with a chronic persistent leak or anastomotic stricture were treated definitively using a SEMS. Although endoluminal stents may not lead to resolution of a chronic leak or stricture, SEMS may suppress ongoing sepsis and allow patients to undergo nutritional resuscitation orally before operative correction.     

Free Jejunal Graft for Reconstruction of Defects in the Hypopharynx and Cervical Esophagus Following the Cancer Resections

Objectives  The reconstruction of esophagus defects after hypopharyngeal and cervical esophageal carcinoma resection is an ongoing problem. The objective of this article was to investigate the techniques of the free jejunal graft for the reconstruction of hypopharyngeal and cervical esophagus and discuss the outcome related to the procedures. Subjects and methods  From July of 2005 to December 2007, seven patients with hypopharyngeal and cervical esophageal cancer underwent free jejunal graft reconstruction of the hypopharyngeal and cervical esophagus. Their clinical data were retrospectively analyzed. All patients received postoperative radiotherapy and were followed up for 7–24 months. Results  Despite the multistep and time-consuming procedure, free jejunal graft survival was 100%. Operation-induced complications did not occur in six patients. One patient developed pharyngeal fistula. Conclusion  The present experience supports the use of free jejunal grafts in reconstruction of the hypopharyngeal and cervical esophagus defects after exenteration of the central compartment of the neck. A high successful rate with low incidence of complications in reconstruction of the hypopharyngeal and cervical esophagus was obtained in this study.     

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

Background  Esophagorespiratory fistulas are serious complications of esophageal tumors. The main goal of this study was to reveal their characteristics. Methods  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. Results  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). Conclusions  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.     

Double stent for malignant combined esophago-airway lesions

OBJECTIVE: Combined esophago-airway stenosis and/or esophago-airway fistula due to malignancy bodes a dismal prognosis. We describe our work with double stents for combined esophago-airway lesions. METHODS: Between February 1994 and July 2000, we treated 11 patients using double stents--the Dumon stent for the airway and the covered Ultraflex for the esophagus. Double stenting was necessitated by combined esophago-airway stenosis in 8 patients and fistulas in 3, of these, 6 had lung cancer and 5 esophageal cancer. RESULTS: In all but 1 ventilator-dependent patient, dyspnea and dysphagia were significantly reduced and fistula was successfully closed after double stenting. This palliation effectively continued more than 1 month in 5 patients, more than 2 months in 3, and more than 3 months in 2. Mean survival was 64 days (range: 9 to 148 days). Life-threatening complications developed in 5 (45%)--massive bleeding in 3 and uncontrollable esophago-airway fistula in 2. All 5 had received prior radiation. CONCLUSION: Although patients who received radiation frequently had life-threatening complications after double stenting, this procedure improved the quality of life in patients with esophago-airway stenosis or fistulas due to lung or esophageal cancer.     

Use of Intercostal Flap for Conservative Surgical Management of Complex Lower Esophageal Fistula

Lower esophageal fistula is a rare complication after upper digestive tract surgery, but it is associated with high morbi-mortality. There is no consensus on therapeutic care, however when reoperation is necessary, a pedicled intercostal flap from the thoracotomy can be easily harvested to patch a large defect or buttress a direct suture, saving digestive reconstruction. This technique should be mastered by thoracic and general surgeons.

We present here two cases of lower esophagus fistulas cured thanks to this intercostal flap, in which we avoided fistula recurrence with maintenance of digestive continuity.     

Enteral Stents for Malignancy: A Report of 46 Consecutive Cases over 10 years,with Critical Review of Complications

Background  Current management of malignant gastric outlet obstruction (GOO) includes surgical diversion or enteral stent placement for unresectable cancer. We analyzed the long-term results, predictive factors of outcomes, and complications associated with enteral stents with focus on their management. Methods  Between 1997 and 2007, 46 patients with malignant GOO underwent placement of self-expandable metal stents (SEMS) for palliation. Patients were captured prospectively after 2001 and followed until complication or death. Patency, management of complications, and long-term survival were analyzed. Results  Forty-six patients had a mean survival of 152 ± 235 days and a mean SEMS patency rate of 111 ± 220 days. SEMS patency rates of 98%, 74%, and 57% at 1, 3, and 6 months were seen. Thirteen patients presented with obstruction and included two SEMS migration, two early occlusion, one fracture, four malignant ingrowth, and four with delayed clinical failure. Interventions included seven endoscopic revisions with three SEMS replacements. Six had percutaneous endoscopic gastrostomy with jejunal arm placed. Two patients eventually underwent surgical bypass. Two patients required surgery for complications including delayed duodenal perforation and aortoenteric fistula. Conclusions  SEMS effectively palliate gastric outlet obstructions that result from upper gastrointestinal malignancies. Their benefits offset potential complications or malfunctions, when a pluridisciplinary approach is adopted. Presented at Digestive Disease Week/SSAT, May 2008, San Diego, California.