Successful endoscopic dilatation to alleviate airway suffocation in a case with esophageal cancer after stent implantation

A case of esophageal cancer who suffered from tracheal stenosis at the tracheostomy after stent implantation is presented. The patient received a covered metallic tracheal stent to seal the esophago-respiratory fistulation. After six months, the tracheal retainer for his tracheostomy was difficult to insert into his trachea due to the growth of the cancer. Argon plasma coagulation (APC) has been successfully employed in the dilatation of tracheal stenosis at the tracheostomy. We herein describe the use of APC as an effective treatment for further palliative therapy of tracheal dilatation in order to treat tracheal stenosis by esophageal cancer after stent implantation.

Three new cases of congenital agenesis of the trachea

Congenital absence of the trachea is a rare anomaly that might confront the obstetrician or neonatologist with an unexpected emergency. These patients present with cyanosis, severe respiratory distress, insufficient gas exchange, absence of audible crying and difficult or impossible endotracheal intubation. In more than 90% it is associated with further congenital malformations. Adequate oxygenation depends on the existence of a tracheo- or bronchooesphageal fistula and the length of the proximal trachea. We present the cases of three neonates with tracheal agenesis with tracheooesophageal fistula. Two of the neonates died within the first hour of life because endotracheal intubation was impossible and oxygenation through an oesophageally placed tube was insufficient. The third infant could be oxygenated through a tracheooesophageal fistula. The ventilation was at least insufficient and no surgical intervention was made. The diagnosis of a congenital absence of the trachea usually is made after birth because of the clinical signs and the course within the first minutes of life. The only way that the diagnosis can be made prenatally is by magnetic resonance imaging (MRI). The knowledge of this clinical picture helps to make decisions in an unexpected emergency in the immediate postpartum period and also in patients whose ventilation is very difficult right from the start.

Erosion of an Esophageal Endoprosthesis Into the Trachea

Acquired benign non-neoplastic tracheoesophageal fistulas are unusual, demanding clinical entities. Surgical technique and final outcome depends on fistula size. A one-stage procedure with esophageal resection is preferred when the fistula is located in the upper third of the trachea and is less than 1 cm long.

Esophageal Stents: Findings on Esophagography in 46 Patients

OBJECTIVE

The purpose of this report is to assess the findings on esophagography in patients with esophageal stents for palliation of malignant tumors involving the esophagus.

CONCLUSION

Radiologists should be familiar with findings of little importance (stent narrowing, flow of contrast medium around stent, stent kinks, and apparent esophageal narrowing below stent because of incompletely distended hiatal hernias) versus more important findings (polypoid defects above or below stent, narrowing within or below stent, delayed stent emptying, esophageal-airway fistulas, stent migration, and abutting of distal stent against greater curvature of stomach) on esophagography after stent placement to guide endoscopists regarding the need for stent revision.

Expandable wallstents for treatment of tracheoesophageal fistulas of malignant origin

PURPOSE

To present our experience with endoscopic placement of esophageal endoprosthesis with self-expandable wallstents in patients with malignant tracheoesophageal fistulas.

PATIENTS AND METHODS

16 patients were retrospectively evaluated, in whom 16 stents were positioned at the esophagus because of tracheoesophageal fistulas: 12 of them suffered of malignant tumors of the esophagus and 4 of malignant tumors of the lung. All stents were placed with guide wire. We used self-expandable wallstents with internal silicon-basedcovering with flared ends, made of a stainless-steel alloy woven into a tubular mesh.

RESULTS

Stents were successfully places in all patients. No procedure-related mortality or significant morbidity occured. Two patients complained of transient swallowing discomfort, but none of them required any additional analgesia. Thirty-day mortality was nil. Immediate leak occlusion was obtained on erect contrast assessment after the procedure in all patients.

CONCLUSION

Self-expandable wallstents endoprosthesis in the esophagus for fistulas of malignant origin is an easy, well tolerated, safe and effective procedure without important complications or mortality.

Traumatic tracheoesophageal fistula in a 5-year old

Tracheosophageal fistula following blunt trauma is rare and diagnosis and management can be difficult. All reported cases have involved victims above 12 years of age. Here we report the anesthesia management, for surgery, of a tracheoesophageal fistula caused by blunt trauma in a 5-year-old boy.

Tracheoesophageal fistula in a child after blunt chest trauma

Traumatic tracheoesophageal fistula is a rare complication after blunt chest trauma, with all reported cases being more than 12 years of age. We report a 5-year-old boy with traumatic tracheoesophageal fistula after a blunt injury to the chest.

Three-layer closure of a tracheoesophageal puncture site: a technical note

A tracheoesophageal voice prosthesis is highly effective in promoting good speech after total laryngectomy. However, long-term use of this device occasionally results in the development of fistulas that must be closed, usually at the request of the patient, because of leakage of saliva and food around the prosthesis. This report describes a technique for simple 3-layer closure of the tracheoesophageal puncture site; other procedures are discussed in light of the current literature.

[A case of advanced esophageal cancer with suspected tracheoesophageal fistula that responded to chemoradiotherapy]

Chemoradiotherapy combined cisplatin, 5-FU and radiation was carried out in an advanced esophageal cancer with suspected tracheoesophageal fistula after insertion of an expandable metallic stent. Regression of the primary tumor was observed, and oral intake could be started. Chemoradiotherapy after insertion of the expandable metallic stent was useful in this case of advanced esophageal cancer with suspected tracheoesophageal fistula.

Salvage of a massive esophago-tracheal fistula resulting from a stenting treatment

We report the successful surgical resolution of a case of massive esophago-tracheal fistula (ETF) caused by a stenting treatment for stricture of an esophago-gastric anastomosis. A 54-year-old man was admitted to our hospital due to serious pneumonia secondary to ETF. He had previously received esophagectomy and post-operative chemo-radiation therapy for esophageal cancer, followed by stenting treatments for a benign stricture of the esophago-gastric anastomosis. For surgical treatment of the resulting ETF, serial operations were required. The first operation, performed under percutaneous cardiopulmonary support, included removal of the stents followed by tracheotomy, were with the coverage of the tracheal defect achieved using both major pectoral muscle flaps. A salivary fistula was also generated and an enteral nutrition tube was placed. Six months after the first operation, a pedicled ileocolic interposition was performed in order to effect reconstruction of the digestive tube, with an additional microvascular anastomosis of the ileocolic and internal thoracic artery and vein. After the second operation, the patient's ability to ingest food was restored, and he was discharged from the hospital. Thus, ETF was successfully treated by successive surgical operations with delicate intra- and post-operative respiratory management.

Complication of mediastinal mass: acquired tracheoesophageal fistula associated with T-cell lymphoblastic lymphoma

The occurrence of a tracheoesophageal fistula (TEF) in the setting of lymphoma has only rarely been reported in the world literature. Most cases reported were associated with radiation therapy vs. chemotherapy alone. This report presents one case illustrating the difficulty encountered managing a TEF that developed while undergoing chemotherapy for T-cell lymphoblastic lymphoma.

First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer

BACKGROUND

Transthoracic esophagectomy with extended lymph node dissection is associated with higher morbidity rates than transhiatal esophagectomy. This morbidity rate could be reduced by the use of minimally invasive techniques. The feasibility of robot-assisted thoracoscopic esophagectomy (RTE) with mediastinal lymphadenectomy was assessed prospectively.

METHODS

This study investigated 21 consecutive patients with esophageal cancer who underwent RTE using the Da Vinci robotic system. Continuity was restored with a gastric conduit and a cervical anastomosis.

RESULTS

A total of 18 (86%) procedures were completed thoracoscopically. The operating time for the thoracoscopic phase was 180 min (range, 120-240 min), and the median blood loss was 400 ml (range, 150-700 ml). A median of 20 (range, 9-30) lymph nodes were retrieved. The median intensive care unit stay was 4 days (range, 1-129 days), and the hospital stay was 18 days (range, 11-182 days). Pulmonary complications occurred in 10 patients (48%), and one patient (5%) died of a tracheoneoesophageal fistula.

CONCLUSIONS

In this initial experience, robot-assisted thoracoscopic esophagectomy was found to be feasible, providing an effective lymphadenectomy with low blood loss. Standardization of the technique and increased experience should reduce the complication rate, which is in the range of the rate for open transthoracic dissection.

Novel method of closing a tracheo-oesophageal fistula using a de-epithelialized deltopectoral flap

The authors describe a novel use of a de-epithelialized deltopectoral flap for the closure of tracheo-oesophageal fistulae, which have been resistant to other methods of closure.

The management of treatment-related esophageal complications in children and adolescents with cancer

BACKGROUND AND PURPOSE

Serious treatment-induced esophageal strictures and tracheoesophageal fistulae are rare in the pediatric oncology population. This report details our experience with their management.

METHODS

We retrospectively reviewed our experience with pediatric oncology patients treated for esophageal complications over a 23-year period. Serious complications were defined as development of strictures requiring dilatation or an esophageal fistula. Fifteen patients were identified, 5 of which had been previously reported.

RESULTS

Thirteen patients developed esophageal stricture, and 2 progressed to tracheoesophageal fistulae. The remaining 2 patients developed tracheoesophageal fistulae without antecedent stricture. The median interval from cancer diagnosis until development of esophageal complications was 3.5 years (range, 0.4-11.8 years). Before development of esophageal complication, 14 patients (93%) were treated with mediastinal radiation and 7 (47%) for candidal esophagitis. Strictures were most commonly located in the distal esophagus (5), then midesophagus (3), cervical esophagus (3) and diffusely (2). A median of 5 dilatations (range, 1-50) were necessary before patients were able to resume a normal diet. The origin of tracheoesophageal fistulae was the midesophagus (3) and distal esophagus (1). All 4 patients with fistulae were treated with esophageal division and diversion followed by esophagocoloplasty.

CONCLUSIONS

Esophageal strictures and fistulae may occur because of cancer therapy in childhood. Prevention includes early treatment of esophagitis especially Candida mucositis, and minimization of radiation dose to the esophagus. Strictures usually respond to dilatation, but fistulae require esophageal diversion and secondary reconstruction.

[The custom-fit voice prosthesis, for treatment of periprothetic leakage after tracheoesophageal voice restoration]

BACKGROUND

Leakage around an indwelling voice prosthesis is detected during 13% up to 27% of all replacement procedures of voice prosthesis and causes serious complications in further voice restoration of the laryngectomee. Lots of therapeutic options to stop periprothetic leakage have been described (Injection of Bioplastique, autologous fat or collagen, suture techniques, spacer therapy) without convincing success rates.

METHODS

Custom-fit voice prostheses are ordinary indwelling voice prostheses (Blom-Singer low pressure Indwelling 20 fr) with enlarged flanges and reduced shaft length that are individually sized for the shunt of the laryngectomee. Especially enlarging the esophageal flange provides a tight sealing of leakage around the prosthesis.

PATIENTS

In a one year lasting clinical trial 692 voice prostheses were changed. In 77 cases periprothetic leakage was detected and fistulas were fitted with individually sized voice prostheses.

RESULTS

In 76 cases total control of leakage was achieved without any specific complications taking place. Moreover two types of leaking tracheoesophageal fistulas were distinguished, a dilated-atrophic and an infected-necrotic type. 57% of the fistulas were dilated-atrophic type and 43% of the fistulas were classified infected-necrotic type. Infected-necrotic fistulas needed enlarged flanges tracheal an esophageal for tight sealing in 91% of the cases whereas dilated-atrophic fistulas needed double flanges only in 45%. 70% of infected-necrotic type fistulas needed only one singular history of a custom-fit prosthesis and could be changed back to ordinary indwelling prostheses after healing had taken place.

CONCLUSIONS

As the insertion of a modified prosthesis is only slightly more effort than an ordinary voice prosthesis insertion, the success rate is high und complications are rare we recommend the custom-fit voice prosthesis for treatment of periprothetic leakage.

Tracheo-esophageal fistula: combined surgical and endoscopic approach

We present a case of benign acquired tracheo-esophageal fistula caused by cuffed tracheal tube. The patient was septic and weaning from the mechanical ventilation was unlikely, so immediate repair of the tracheal and esophageal lesions was imperative. A silicone endoprosthesis was inserted in the tracheal lumen and the esophageal lesion was repaired with direct suture. After weaning from mechanical ventilation and recovery, the patient was discharged with a silicone tracheal stent. Three months later the stent was removed without complications or need for further treatment. This combined approach as never been published before, and can be a very useful alternative for the treatment of this rare but taxing complication.

A missing denture's misadventure!

We report a late onset, benign, tracheoesophageal fistula in a 51-year-old man, due to an accidentally swallowed denture. In view of the extensive peri-esophageal sepsis and fibrosis, he was managed by a subtotal esophagectomy and a cervical esophagogastric anastomosis. The tracheal defect was closed with the help of an intercostal muscle flap. This report also highlights the difficulty in identifying swallowed prosthetic dental material radiologically, when no metallic component is present. This fact was also responsible for the delay in diagnosis, eventually leading to the rare complication of a tracheoesophageal fistula.

[Esophago-respiratory fistulas of tumorous origin]

Esophago-respiratory fistulas developing in malignant disease have serious consequences by continuous airway contamination. Between 1984 and 1999 in the 1st Department of Surgery of Semmelweis University 1439 patients were treated with esophageal cancer. During regular examinations esophago-respiratory fistulas were detected in 163 patients (11.3% incidence). By analyzing data about these patients, we examined the causes, the characteristics of the disease and the possibilities and the efficiency of treatment. The mean age of these 163 patients was 55 (21-83) years, the ratio between men and women 3.7:1. By analyzing data of these patients according to their age, history, degree of dysphagia, weight loss, tumor size and survival rate, it can be noticed that there are two specific peaks, which differs from the average patients with esophageal tumors. Presumably, patients with esophago-respiratory fistulas can be divided into two groups. One consists of relatively younger patients with biologically more aggressive carcinomas, while the other group is of older patients where the fistula formation is the end stage of the slower progressing tumor. Twenty eight patients received irradiation before the fistula developed, most likely the longer survival rate contributed to the rise of the number of the fistulas. Ninety-five patients underwent endoscopic endoprosthesis implantation, 24 had the position of a stent corrected, 44 patients received palliative therapy, gastrostomy was performed in 15 patients. The median survival period was 5.0 months (0-46 months). Patients with endoprosthesis, gastrostomy and palliative treatment only had mean survival periods of 6.2 (1-46), 1.7 (0-5) and 1.6 (0-5) months. By sealing off the fistula, a successful endoscopic stent can end the serious airway contamination and the dysphagia, improving the quality of life and length of survival. Endoscopic endoprosthesis implantation is a feasible method in the treatment of patients with esophago-respiratory fistula.

[A case report of esophageal cancer with tracheoesophageal fistula--improving the quality of life by using a covered self-expandable metallic stent]

We present the case of a 64-year-old male who was diagnosed with esophageal cancer with tracheal invasion and distant lymph node metastases, and he received chemoradiation therapy. The therapy resulted in complete remission. However, he was unable to eat anything because of missed swallowing caused by a large tracheoesophageal fistula. The placement of a covered self-expandable metallic stent (SEMS) improved his quality of life and palliated dysphagia for 3 months. Stenting in the cervical or upper esophagus may cause discomfort. However, the placement of a covered SEMS is one of the useful palliative treatments for esophageal cancer with tracheoesophageal fistula.

Traitement des fuites sur prothèse phonatoire

Numerous voice prostheses have been developed since the early eighties. The device, located in the tracheo-esophageal wall, can generate local complications. The most frequent and the hardest to treat is peri-prosthetic salivary leakage.

OBJECTIVE

To present a new management scheme for peri-prosthetic salivary leakage by BIOPLASTIQUE injection.

PATIENTS AND METHOD

Five patients, with residual peri-prosthetic salivary leakage after different treatments were managed by peri-prosthetic injection of BIOPLASTIQUE, a medical silicone elastomere. The injection was performed under general anesthesia in four points around the prosthesis: above, below, left and right.

RESULTS

Leakage disappeared after one or two injections in all patients. No technical problem was encountered.

CONCLUSION

Although this method still has to pass the test of time, our preliminary results are encouraging. Such a procedure could be performed under local anesthesia in order to minimize its cost.

[Aortopexy in the surgical treatment of tracheomalacia in children]

Aortopexy was performed in 55 patients for respiratory ways obstruction of various origin. There were estimated immediate and late follow-up results of aortopexy application, solely or in conjunction with tracheoplasty in 11 patients, ageing from 1 mo to 5 years, performed for tracheomalacia, which included idiopathic, associated with esophageal atresia and tracheoesophageal fistula forms. Local tracheomalacia was revealed in 8 patients, diffuse--in 3. In 6 observations aortopexy was conducted only, in 5 - aortopexy in conjunction with tracheoplasty using pericardial or fasciopleural flaps. In presence of esophageal disease concominantly its segmental resection of cicatricially changed portion was performed, as well as the recurrent tracheoesophageal fistula division and suturing. Generally, positive result in immediate and late follow-up period was noted in all the patients. In 3 patients there was revealed incomplete stabilization of trachea with the membranous portion of the wall expulsion up to 1/2 of lumen and persistence of nonsignificant respiratory symptoms, caused by presence of gastro-esophageal reflux. The results obtained witness, that aortopexy constitutes an effective method of surgical treatment of respiratory ways obstruction, caused by tracheomalacia. The presence of diffuse tracheomalacia needs additional tracheoplasty to the aortopexy performance.