[Usefulness of esophageal stenting for esophagorespiratory fistula with esophageal cancer]

We evaluated the outcome of esophageal stenting for esophagorespiratory fistula in patients with advanced esophageal cancer. Six patients with such fistula underwent esophageal stenting at our department from January 2000 to May 2012. Intraoral ingestion improved in all patients. Cough decreased immediately after stenting in 3 patients, and pneumonia detected by chest radiography improved within 1 week in 2 patients. Ventilation was weaned 2 days after stenting in 1 patient. The median survival duration after stenting was 31 days, and the cause of death was cancer in all patients. The following background factors were identified at the time of death: bleeding(n=3), mediastinitis(n=1), and pneumonia(n=1). Esophageal stenting, which should always be performed with the informed consent of the patient, improves respiratory symptoms, intraoral ingestion, and quality of life. Therefore, it is one of the best palliative therapies for patients with esophagorespiratory fistula associated with advanced esophageal cancer.

Comparative study of esophageal stent and feeding gastrostomy/jejunostomy for tracheoesophageal fistula caused by esophageal squamous cell carcinoma

BACKGROUND

A malignant tracheoesophageal/bronchoesophageal fistula (TEF) is a life-threatening complication of esophageal squamous cell carcinoma. A feeding gastrostomy/jejunostomy had been the most common treatment method for patients with TEF before the era of stenting. The aim of this retrospective study is to compare the prognosis of esophageal squamous cell carcinoma patients with TEF treated with an esophageal metallic stent to those treated with a feeding gastrostomy/jejunostomy.

METHODS

We retrospectively reviewed a total of 1011 patients with esophageal squamous cell carcinoma between 1996 and 2011 at Kaohsiung Chang Gung Memorial Hospital, and 86 patients with TEF (8.5%) were identified. The overall survival and other clinical data were compared between 30 patients treated with an esophageal metallic stent and 35 patients treated with a feeding gastrostomy/jejunostomy.

RESULTS

Among the 65 patients receiving either an esophageal metallic stent or a feeding gastrostomy/jejunostomy, univariate analysis showed that treatment modality with an esophageal metallic stent (P = 0.007) and radiotherapy treatment after fistula diagnosis (P = 0.04) were predictive of superior overall survival. In the multivariate comparison, treatment modality with an esophageal metallic stent (P = 0.026, odds ratio: 1.859) represented the independent predictive factor of superior overall survival. There were no significant differences between groups in mean decrease in serum albumin or mean body weight loss. Compared to the feeding gastrostomy/jejunostomy group, a significantly higher proportion of patients in the stenting group (53% versus 14%, P = 0.001) were able to receive chemotherapy within 30 days after fistula diagnosis, indicating better infection control in the stenting group.

CONCLUSIONS

Compared with a feeding gastrostomy/jejunostomy, an esophageal metallic stent significantly improves overall survival in patients with malignant TEF in our retrospective analysis. Esophageal metallic stent placement may be considered the first-line of treatment for patients with malignant TEF.

Tracheo-esophageal fistula secondary to tracheostomy, delayed diagnosis

Persistent air leak is not a common problem in patients who are under mechanical ventilation support; however, it can be encountered in intensive care unit (ICU). It is often due to nonuniform contact between the cuff and the tracheal wall caused by insufficient cuff pressure or malposition of the tube. Tracheostomy is commonly applied and is a relatively safe invasive procedure in ICU. We report a case of tracheoesophageal fistula (TEF), secondary to tracheostomy, initially manifested with persistent air leak under mechanical ventilation in ICU. Consequently, TEF should be considered in patients with unexplained upper airway leaks.

[Congenital esophageal stenosis owing to ectopic tracheobronchial remnants: report of four cases and review of the literature]

OBJECTIVE

Congenital esophageal stenosis owing to tracheobronchial remnants (TBR) is a rare condition. This study was conducted to understand the clinical features of TBR.

METHOD

The data of the four cases with TBR admitted to our hospital and 76 patients identified from the literature were reviewed. The clinical manifestation, X-ray, endoscopy, biopsy and treatment were studied retrospectively.

RESULT

Of the total of 80 cases, 45 were male, 33 were female, and for 2 cases the gender was unknown. Symptoms of dysphagia and regurgitation developed at the age of 1-day to 12-month. Definitive treatment was carried out at the age of 1-month to 16-year. Twenty-seven patients had associated anomalies with esophageal atresia being the most prevalent. X-ray esophagography showed segmental stenosis at the distal third of the esophagus in all patients except three. An abrupt narrow segment at the lower esophagus with marked proximal dilatation was found in 32 cases. Esophagography of 12 cases showed distal esophageal stenosis with tapered narrowing. Esophagography of 20 cases showed flask-shaped shadow of distal esophageal stenosis and one patient showed linear projection of barium at the level of stenosis. Endoscopy found almost complete obstruction of the lower esophageal lumen without signs of the esophagitis or reflux. Esophagoscopic dilatation of the stenosis was attempted in 24 cases, but was ineffective, and 3 patients suffered esophageal perforation. Seventy-nine patients underwent resection of the stenotic segment. Histologic examination of the resected specimen showed cartilage, mucus glands, resembling bronchal tissue. Post-operative complication included anastomotic stenosis, anastomotic leakage, hiatal hernia, and gastroesophageal reflux.

CONCLUSION

TBR should be suspected in patients who present with a typical history of dysphagia after ingestion of solid food. Esophagography and esophagoscopy are the essential means for diagnosis. TBR should be different from achalasia and should be diagnosed by biopsy. Operation is the only choice of treatment.

Endoscopic palliative treatement of a post-radiation tracheoesophageal fistula

Malignant Tracheoesophageal Fistula (TEF) is a life-threatening condition and conventional palliative surgical approach sometimes could be very dangerous or not suitable. We describe a case of a post-radiation TEF involving distal trachea and main carina treated by the placement of endotracheal silicon stent.

Corrosive tracheo-esophageal fistula following button battery ingestion

We describe a case of corrosive tracheo-esophageal fistula following button battery ingestion in a 1-year old nonverbal pediatric patient. The delay in diagnosis was caused by failure to obtain correct history and failure to detect opacity of the battery in the neck at the first visit. The large fistula was successfully treated with division and repair with non absorbable sutures, with interposition of strap muscles between separated trachea and esophagus.

Acquired nonmalignant tracheoesophageal fistula

Acquired nonmalignant tracheoesophageal fistula is a rare clinical entity and a difficult problem to diagnose and manage. We report a 59-year-old woman diagnosed with a tracheoesophageal fistula secondary to prolonged intubation. The diagnosis was delayed for a year, hence her mild symptoms; cough and dysphagia mainly to liquids. These symptoms were thought to be side effects of her psychiatric medications especially that she had a buccal and lingual dyskinesia. She later had a trial of conservative treatment that failed and then she underwent surgical resection of the fistula and interposition of a muscle flap. Acquired nonmalignant tracheoesophageal fistula is a preventable disease in intubated patient if some measures are taken, but even with the use of the newer endotracheal tubes (high-volume, low-pressure cuffs) this complication can still occur. The surgical treatment remains the best option.

Tracheoesophageal fistula with tracheal stenosis resulting from retained esophageal foreign body

Although a foreign body ingestion is common in infants and young children, serious complication such as penetration of the esophagus is a relatively rare event. Delayed diagnosis may result from lack of classical symptoms and history, leading to serious result, even to death. A 2-year-old boy was admitted to the emergency room with dyspnea. He had wheezing and stridor for a 1.5-year and unfortunately treated as a bronchial asthma for a long time. Chest X-ray and cervical CT scan revealed esophageal foreign body. Intraoperative findings showed a plastic material in the esophagus and tracheoesophageal fistula with tracheal stenosis as a complication of the retained foreign body. Therefore, we should keep in mind that foreign body can present atypical symptoms like respiratory symptoms, especially in infant and young children.

[Foreign bodies of the esophagus in the adult: report of 26 cases]

INTRODUCTION

The foreign bodies of the oesophagus see each other at any age. They are more frequent at the child's than at the adult. The cutting foreign bodies can constitute an urgency because of the risk of oesophagienne perforing or bleeding.

OBJECTIVE

Bring report the epidemiological and clinical profile of the foreign bodies of the oesophagus in our practice, and underline the difficulties of coverage(care) at the adult.

MATERIAL AND METHOD

A forward-looking study was realized of April, 2007 in Mars 2009 in the service ENT of the University hospital (CHU) Gabriel TOURE of Bamako concerning 26 grown-up patients presenting a foreign body of the oesophagus.

RESULTS

Both sexes are affected in a equivalent way. The average age was of 32 years with extremes of 15 years and 65 years. The patients from 31 to 45 years old were the most touched. The false tooth was the foreign body most frequently met (58 %). Three patients presented complications has type of oesophagienne perforing (2) and of oeso-trachéale fistula (1) the outcome of which was fatal afterward. The oesophagoscopie in the stiff tube under general anesthesia allowed to extract 92 % of the foreign bodies.

CONCLUSION

The foreign body of the oesophagus is a pathology so frequent at the adult and the diagnosis is mostly evident. Among the foreign bodies, false teeth raised problems of therapeutic coverage. The prevention passes by the regular medical supervision of false teeth, the training formation of the staff, the improvement of the technical trayp, and a good education of the patient.

[Possibilities and results of surgical treatment of benign tracheoesophageal fistula]

AIM

Review of literature and a single-institution retrospective analysis of possibilities and results of various surgical techniques in treatment of benign tracheoesophageal fistula (TEF).

MATERIAL AND METHODS

Between 1995 and 2010, 26 patients with benign tracheoesophageal fistula of various etiology underwent surgical treatment at the Department of Thoracic Surgery of Slovak Medical University and Faculty Hospital in Bratislava. The majority of patients had a postintubation TEF (21 cases), two fistulas were of traumatic origin, one iatrogenic, one congenital with adulthood manifestation and one tracheo-neoesophageal (TNEF) following an esophagectomy for carcinoma via extended cervical approach with lymphadenectomy and sternal retraction adpoted from transcervical extended mediastinal lymphadenectomy. We review the possible means of surgical treatment of TEF, of which we most frequently used segmental tracheal resection with end-to-end anastomosis and a non-overlying suture of the esophageal defect without muscle flap interposition (16 patients), transsection of the fistula with muscular flap interposition via cervical (2 patients) or transthoracic (1 patient) approach; or a T-tube insertion with (1 patient) or without (5 patients) discision and suture of the TEF. The only tracheo-neoesophageal fistula in our experience had been treated by neoesophagectomy, covering of tracheal defect by intercostal muscle flap and cervical esophagostomy.

RESULTS

Short- and long-term results of TEF treatment in our institution have been favourable, with perioperative mortality of 3.8% (the patient with tracheo-neoesophageal fistula). Morbidity included 1 partial tracheal anastomotic dehiscence, 3 temporary left recurrent nerve palsies, temporary deglutition disorders (15 patients), tracheal anastomosis granulations in 1 patient and 2 wound infections. Out of 26 patients 15 (58%) are being followed-up on a regular basis, all with good (12 patients) or satisfactory (3 patients) functional results.

CONCLUSION

In the paper we analyze the advantages and disadvantages of various techniques and their alternatives in the treatment of TEF. As the most reliable and suitable solution for patients with postintubation TEF, breathing spontaneously and with acceptable nutritional status, we favour segmental trachea resection with end-to-end anastomosis and esophageal suture without muscle interposition, regardless of presence of concomitant tracheal stenosis. Fistulae of other etiologies require diverse approaches, especially tailored with respect to their location. Management of tracheo-neoesophageal fistula following esophagectomy for carcinoma is extremely demanding. Therefore, it is crucial to adhere to basic rules of prevention of such benign but potentially fatal entities as TEF and TNEF.

[Tracheal stenosis--diagnostic and therapeutic principles, results]

Between November 2001-April 2010, 107 tracheal resections were performed in our department for different types of tracheal stenosis: iatrogenic or tumoral, benign or malignant. We present the diagnosis and treatment principles that we used, along with our results. We operated on 74 (69.15%) iatrogenic postintubation tracheal stenosis, 6 (5.6%) of them complicated with tracheo-esophageal fistula, 6 (5.6%) benign tumors, 11 (10.28%) primary malignant and 16 (14.97%) secondary malignant ones, with a 3.8% total mortality. Tracheal resection and reconstruction is the only curative treatment for all types of tracheal stenosis. Interventional endoscopy is of a major importance in the assessment and treatment of tracheal stenosis. We believe that each patient diagnosed with a tracheal stenosis should be referred to a tertiary center with multidisciplinary experience in the treatment of tracheal stenosis.

[Treatment of tracheoesophageal and tracheopharyngeal fistulas after laryngectomy]

Tracheoesophageal (TEF) and tracheopharyngeal fistulas (TPF) after laryngectomy can mainly be divided into five types: "high TEF with leakage through the voice prosthesis (VP)" (Type Ia), "high TEF with leakage around the VP" (Type Ib), "enlarged high TEF" (Type II), "deep TEF" (Type III), "TPF" (Type IV) and "TPF associated with pharynx stenosis" (Type V). Leakage of TEF in prosthetic voice restoration usually responds well to conservative measures. If these measures fail, as well as in all cases of TPF, surgical intervention is necessary for transtracheostomal or transcervical closure with multi-layer sutures of the esophagus and trachea. In persisting TEF/TPF after unsuccessful surgical attempts revision surgery remains challenging. Tracheostoma transposition for dissociation of the cranial end of the trachea and the hypopharynx and esophagus is essential for effective closure. In rare cases of TPF combined with pharyngoesophageal stricture formation a resection and immediate reconstruction of the stenotic pharyngoesophageal segment with a tube-shaped fasciocutaneous radial forearm flap must be considered.

[Distal trachea and bronchial large lesions and suture reinforcement with Polyglicol Acid (PGA) patch. First clinical experience]

BACKGROUND

Iatrogenic lacerations of the trachea and the bronchies are mostly complications of emergent intubations or percutaneous tracheotomies. The outcome is mainly influenced by thorough diagnostics, severity of the lesions, and urgent treatment. New materials are used to reduce the tension at the sutured points during ventilation.

PATIENTS AND METHODS

Four patients were operatively treated with primary suturing of trachea and bronchies with Polydioxanon. The large wounds were then covered using resorbable Soft PGA Mesh (resorbable Polyglykol Acid patch). The first two patients were found hypoxic and was orotracheally intubated in an emergency. An air leckage was detected in the hospital due to a large lesion of the pars membranacea. The third patient was operated in an emergency due to ileus caused by progressive colonic carcinoma. The weaning period on Intensive Care Unite (ICU) was unsuccessful. In a difficult procedure she underwent a percutaneous tracheotomy (dystopia of the trachea due to an arteria lusoria) mainly resulting in esophagotracheal fistulae. The fourth patient was treated by esophagectomy due to a local progressive carcinoma. A long lesion between the carina and left main bronchus resulted. All lacerations were treated by single knot suture technique with Polydioxanone and finally covered (patched) with PGA Mesh. The outcome of the surgical treatment was analyzed.

RESULTS

In bronchoscopies and CT-scans no air leackages during respiratory ventilation periods were observed. The first patient could be transferred into a normal ward from ICU at day 38. The second patient was found to be tetraplegic and was discharged into another hospital at day 48. One patient died at the 15th postoperative day due to urosepsis. The fourth patient left the ICU on day 10 and was discharged home at day 23.

CONCLUSIONS

Large iatrogenic airway lacerations of the distal trachea should be managed by early surgical repair due to their life-threatening outcome. Although only a small number of patients were analyzed so far, a PGA Mesh might be useful to increase the suture safety reducing the tension at the suture points due to the cuff pressure during long ventilation periods.

[Analysis of traumatic laryngotracheal stenosis in 63 cases]

OBJECTIVE

To explore the surgical treatment and the principle of selecting approaches in traumatic laryngotracheal stenosis.

METHODS

Sixty three cases of traumatic laryngotracheal stenosis treated in the Department of Otolaryngology, Head and Neck Surgery, Chinese People's Liberation Arauy General Hospital from 1993-2006 were reviewed. The surgical treatment and the effects were analyzed.

RESULTS

Among the 63 cases, 99 operations were accomplished in total, excluding tracheotomy and the closure operation for the fistula. Forty patients had experienced one operation (63.5%), 15 cases (23.8%) had 2 operations, 5 cases had 3 operations, 2 cases had 4 operations, and one case had 6 operations. Fifteen initially estimated as laryngotracheal stenosis with intact framework had supporting laryngoscopic surgery, 11 cases decannulated successfully after single operation. Primary laryngotracheal split and plasticity with T tube implantation were accomplished in 36 cases, with 20 cases decannulated. Among 10 cases experienced laryngotracheal split, skin graft in laryngotracheal cavity with T tube implantation, 7 decannulated. Among 6 cases of laryngotracheal split, pedicled hyoid flap transfer for reconstruction of the laryngotracheal framework defect, 4 cases decannulated. Tracheal and cricotracheal resection and end-end anastomosis were performed in 9 cases, 7 cases decannulated after single procedure. Two cases of subglottic stenosis with tracheoesophageal fistula were repaired with laryngotracheal plasticity in single procedure successfully. Fifty seven patients were decannulated after different procedures with variable hoarseness, within 6 months to 5 years follow-up. Six cases failed in decannulation. The decannulation rate was 90.5%.

CONCLUSIONS

Traumatic laryngotracheal stenosis is a complex problem that usually needs a longer time for reconstruction and a different ways of approaches. It is necessary to evaluate the laryngotracheal framework defect, the degree and extension of stenosis systematically before operation for surgical planning.

Maternal periconceptional exposure to cigarette smoking and alcohol and esophageal atresia +/- tracheo-esophageal fistula

BACKGROUND

Esophageal atresia (EA) is a moderately frequent birth defect that often occurs with tracheo-esophageal fistula (TEF). Etiologic studies for EA+/-TEF have produced inconsistent results.

METHODS

This study used data from the National Birth Defects Prevention Study (NBDPS) to examine the association between maternal periconceptional exposure to cigarette smoking and alcohol and EA+/-TEF. Cases of EA+/-TEF and unaffected controls with an estimated date of delivery from October 1997 through December 2003 were identified, and telephone interview reports for smoking and alcohol exposure were obtained from birth mothers of 334 cases and 4,967 controls. Odds ratios (OR)s and 95% confidence intervals (CI)s, adjusted for several covariates, were calculated to assess associations.

RESULTS

ORs were near unity for all EA+/-TEF cases combined and any periconceptional exposure to cigarette smoking (OR = 1.1; CI = 0.8,1.6) or alcohol (OR = 1.2; CI = 0.8,1.8). For cigarette smoking, some elevated ORs were found but varied by type of smoking exposure. No consistent patterns were identified for number of cigarettes smoked per day. For alcohol, ORs were weak to moderately elevated with increasing number of drinks consumed and for binge drinkers compared to non-binge drinkers. ORs were further elevated among mothers who reported active+passive exposure to cigarette smoking and alcohol (OR = 2.5; CI = 1.1,5.6). For both exposures, ORs were higher for cases with additional major defects compared to isolated cases.

CONCLUSIONS

These results, based on one of the largest published samples of EA+/-TEF cases, suggest a role for these exposures in the etiology of EA+/-TEF, although further study is needed to replicate the observed associations.

Repair of massive stent-induced tracheoesophageal fistula

OBJECTIVE

The purpose of this report was to discuss a new surgical procedure in treating esophageal stent related large tracheoesophageal fistula without tracheal resection.

METHODS

Clinical records of 5 patients with esophageal stent-related large tracheoesophageal fistulas treated in this hospital between 1997 and 2006 were reviewed.

RESULT

All patients had insertion of a covered self-expanding esophageal stent, 1 for benign esophageal stricture and 4 for esophageal perforation resulting from various causes. A double patch technique, in which the esophageal wall was used as a protective patch repairing the defect on the trachea, was performed with an esophagectomy and gastric replacement. No significant complications occurred in the perioperative period. All patients recovered uneventfully.

CONCLUSIONS

Use of the adjacent esophageal wall as a patch to close a defect on the trachea is a safe procedure with a favorable outcome. It should therefore be recommended as a reliable surgical procedure in treating massive stent-induced tracheoesophageal fistulas and other complicated tracheoesophageal fistulas that tracheal resection could not safely address. However, the esophagus was damaged to a certain degree.