Retroesophageal subclavian artery--esophageal fistula: a rare complication of a salivary bypass tube

Transnasal negative pressure therapy for accelerating healing and improving the prognosis of pharyngocutaneous fistula

BACKGROUND

Pharyngocutaneous fistula (PCF) is one of the most common complications of total laryngectomy. This study is to investigate the efficacy of a novel platform called transnasal negative pressure therapy (TNPT) in the management of PCF.

METHODS

We retrospectively reviewed 47 patients who underwent total laryngectomy between April 2015 and February 2021 and developed PCF in our hospital. We focused on the healing rate, dressing change frequency, and healing time between the TNPT and non-TNPT groups. The 2 years overall survival (OS) was compared through the log-rank test.

RESULTS

There were 18 patients in the TNPT group and 29 in the non-TNPT group. There was no significant between-group difference in the healing rate (chi-square test). However, the frequency of dressing changes was significantly lower (p < 0.001) and the healing time was significantly shorter (p = 0.0194) in the TNPT group than in the non-TNPT group. The 2-year OS rate was significantly higher in the TNPT group (p = 0.0473, log-rank test).

CONCLUSION

TNPT promoted wound healing after surgery for PCF and improved the 2-year OS rate. This tool is worthy of clinical application and promotion.

A designed ladder-shaped stent for the treatment of refractory hypopharyngeal corrosive strictures

BACKGROUND

The treatment of refractory hypopharyngeal corrosive strictures remains challenging nowadays.

OBJECTIVES

To introduce a designed ladder-shaped stent for the treatment of refractory hypopharyngeal corrosive strictures.

MATERIAL AND METHODS

Patients with refractory hypopharyngeal corrosive strictures treated in our hospital between 2018 to 2022 were recruited in this study. All the patients had a dysphasia score of 4 and four patients had a tracheostomy preoperatively. A designed ladder-shaped stent was placed in the hypopharyngeal area after laser treatment to maintain the opening. This stent was kept for 3-6 months. All the patients were followed-up for at least 6 months after stent removal.

RESULTS

Six patients were recruited including two males, three females and one girl. All the patients were tolerable with the stent. There were no immediate or long-term complications. Patients were able to swallow a soft diet after the procedure. No tracheostomy was needed.

CONCLUSION

This use of a ladder-shaped stent is helpful in the treatment of hypopharyngeal strictures after laser treatment.

Massive hemorrhage after arterioesophageal fistula from an unknown aberrant subclavian artery

The aberrant right subclavian artery has an incidence of 0.5%-1% in the population, generally with retroesophageal location. It can lead to the formation of an arterio-esophageal fistula in patients with predisposing risk factors due to devices placed in esophageal or tracheal position, as it is particularly susceptible to extrinsic compression and pressure necrosis. We present the case of a patient with a postsurgical tracheoesophageal fistula, who developed massive bleeding due to an arterioesophageal fistula secondary to an unknown aberrant right subclavian artery. For hemostatic management, alternative maneuvers were performed, such as the placement of a Foley-type urinary catheter at the point of bleeding and the subsequent placement of a Sengstaken-Blakemore balloon in cranial position. Given the severity of the condition and the possible diagnostic delay, it seems appropriate to consider performing a preoperative CT angiography in patients with risk factors who undergo these procedures.

Upper Gastrointestinal Bleeding From Aberrant Right Subclavian Artery-Esophageal Fistula

Background: The most common aortic arch abnormality is an aberrant right subclavian artery (ARSA). ARSA-esophageal fistula is a rare sequela that can present with a life-threatening upper gastrointestinal (GI) bleed. Case Report: We report the case of an 88-year-old male who presented with signs of upper GI bleeding. Esophagogastroduodenoscopy demonstrated extrinsic compression of the upper third of the esophagus with ulceration. Imaging studies revealed ARSA posterior to the esophagus with pseudoaneurysm formation. These findings confirmed an upper GI bleed secondary to ARSA-esophageal fistula. The patient underwent prompt embolization of the ARSA pseudoaneurysm, followed a few days later by coil embolization of the ARSA pseudoaneurysm. Despite these interventions, the patient continued to have bleeding with anemia. He and his family opted to avoid any further interventions and instead pursued comfort care. The patient was discharged to hospice and died 3 months later. Conclusion: ARSA-esophageal fistula is a rare but potentially lethal cause of upper GI bleeding. Initial signs and symptoms can be subtle, but the presence of a GI bleed requires immediate stabilization. Surgical interventions have been shown to have longer-lasting success, but endovascular repair may be an option for patients who are deemed unfit for surgery but still require prompt stabilization. Regardless of the intervention, mortality rates for ARSA-esophageal fistula are high.

Aberrant Left Subclavian Artery-Esophageal Fistula in a Patient with a Prolonged Use of Nasogastric Tube: A Case Report and Literature Review

Arterial-esophageal fistula is a rare but potentially fatal complication. Right aortic arch with aberrant left subclavian artery is a rare congenital vascular anomaly that can cause esophageal compression, particularly when the proximal portion of the aberrant subclavian artery forms a Kommerell's diverticulum. Prolonged use of a nasogastric tube can cause pressure necrosis of the esophagus. We report a patient with massive gastrointestinal bleeding secondary to aberrant left subclavian artery-esophageal fistula after a prolonged use of nasogastric tube. A high index of suspicion is essential for better prognosis when a patient with congenital aortic arch anomaly shows upper gastrointestinal hemorrhage.

Utility of the Montgomery salivary tubes for preventing pharyngocutaneous fistula in total laryngectomy

PURPOSE

To evaluate the prophylactic, protocolized, and standardized use of a Montgomery tube in preventing pharyngocutaneous fistulas after total laryngectomy and neck dissection.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral centre.

SUBJECT AND METHODS

A Montgomery salivary bypass tube was placed in 44 patients undergoing total laryngectomy and neck dissection, observing the percentage of fistula appearance and the time of start of deglutition. Comparison was made with a group of 28 patients prior to the implantation of the protocol in whom the tube was not used.

RESULTS

There was a statistically significant decrease in the percentage of fistulas and an earlier onset of deglutition in the salivary bypass tube patients compared to those in whom the tube had not been used.

CONCLUSION

Prophylactic and standardized use of the Montgomery salivary bypass tube in patients undergoing total laryngectomy and neck dissection might decrease the incidence of pharyngocutaneous fistula and improve the course of one that is already established.

Prevalence and Anatomy of Aberrant Right Subclavian Artery Evaluated by Computed Tomographic Angiography at a Single Institution in Korea

Objective

Aberrant right subclavian artery (ARSA) is a rare anatomical variant of the origin of the right subclavian artery. ARSA is defined as the right subclavian artery originating as the final branch of the aortic arch. The purpose of this study is to determine the prevalence and the anatomy of ARSA evaluated with computed tomography (CT) angiography.

Methods

CT angiography was performed in 3460 patients between March 1, 2014 and November 30, 2015 and the results were analyzed. The origin of the ARSA, course of the vessel, possible inadvertent ARSA puncture site during subclavian vein catheterization, Kommerell diverticula, and associated vascular anomalies were evaluated. We used the literature to review the clinical importance of ARSA.

Results

Seventeen in 3460 patients had ARSA. All ARSAs in 17 patients originated from the posterior aspect of the aortic arch and traveled along a retroesophageal course to the right thoracic outlet. All 17 ARSAs were located in the anterior portion from first to fourth thoracic vertebral bodies and were located near the right subclavian vein at the medial third of the clavicle. Only one of 17 patients presented with dysphagia.

Conclusion

It is important to be aware ARSA before surgical approaches to upper thoracic vertebrae in order to avoid complications and effect proper treatment. In patients with a known ARSA, a right transradial approach for aortography or cerebral angiography should be changed to a left radial artery or transfemoral approach.

Anomalous Right Subclavian Artery-Esophageal Fistulae

An aberrant right subclavian artery (ARSA) is the most common aortic arch anomaly, but only 19 previous cases of ARSA-esophageal fistula have been reported. Six patients have survived their bleeding episode. We describe the case of a 44-year-old woman who developed massive hemoptysis. Laryngoscopy, bronchoscopy, head and neck angiogram, and median sternotomy did not reveal what was presumed initially to be a tracheoinnominate fistula. Contrasted CT showed an anomalous subclavian artery posterior to the esophagus. Given the technical challenge of approaches for this pathology, the patient was unfit for open surgical repair. Therefore, endovascular covered stent grafts were deployed spanning the segment of the subclavian artery in continuity with the esophagus, via a right brachial artery approach. Unfortunately, the patient died after successful placement of the grafts.

Routine use of salivary bypass tubes in laryngectomy patients: systematic review

BACKGROUND

Pharyngocutaneous fistula is a cause of significant morbidity following laryngectomy. Routine use of salivary bypass tubes during laryngectomy has been proposed to reduce the incidence of fistulae and neopharyngeal strictures.

METHOD

Following a systematic search of Embase, Medline and Cochrane databases (1946 - current), included articles were assessed for bias according to the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Three case-control trials showed reduced pharyngocutaneous fistula rates with the use of salivary bypass tubes; six case series reported widely varied fistula rates. With regards to stricture rates, the largest case-control trial found no improvement with salivary bypass tube use. No fatal adverse events were observed among the 204 patients who received a salivary bypass tube.

CONCLUSION

Low-level evidence suggests salivary bypass tubes may reduce the incidence of fistula in high-risk patient groups. A robust randomised controlled trial, or large, multicentre cohort studies, are needed to further examine this intervention.

Do salivary bypass tubes lower the incidence of pharyngocutaneous fistula following total laryngectomy? A retrospective analysis of predictive factors using multivariate analysis

Salivary bypass tubes (SBT) are increasingly used to prevent pharyngocutaneous fistula (PCF) following laryngectomy and pharyngolaryngectomy. There is minimal evidence as to their efficacy and literature is limited. The aim of the study was to determine if SBT prevent PCF. The study was a multicentre retrospective case control series (level of evidence 3b). Patients who underwent laryngectomy or pharyngolaryngectomy for cancer or following cancer treatment between 2011 and 2014 were included in the study. The primary outcome was development of a PCF. Other variables recorded were age, sex, prior radiotherapy or chemoradiotherapy, prior tracheostomy, type of procedure, concurrent neck dissection, use of flap reconstruction, use of prophylactic antibiotics, the suture material used for the anastomosis, tumour T stage, histological margins, day one post-operative haemoglobin and whether a salivary bypass tube was used. Univariate and multivariate analysis were performed. A total of 199 patients were included and 24 received salivary bypass tubes. Fistula rates were 8.3% in the SBT group (2/24) and 24.6% in the control group (43/175). This was not statistically significant on univariate (p value 0.115) or multivariate analysis (p value 0.076). In addition, no other co-variables were found to be significant. No group has proven a benefit of salivary bypass tubes on multivariate analysis. The study was limited by a small case group, variations in tube duration and subjects given a tube may have been identified as high risk of fistula. Further prospective studies are warranted prior to recommendation of salivary bypass tubes following laryngectomy.

Repair of an aberrant subclavian arterioesophageal fistula following esophageal stent placement

A fistula formation between the esophagus and an aberrant right subclavian artery is a rare but fatal complication that has been mostly described in the setting of prolonged nasogastric intubation and foreign body erosion. We report a case of a young morbidly obese patient who underwent sleeve gastrectomy that was complicated by a postoperative leak at the level of the gastroesophageal junction. A covered esophageal stent was placed endoscopically to treat the leak. The patient developed massive upper gastrointestinal bleeding secondary to the erosion of the stent into an aberrant retroesophageal right subclavian artery twelve days after stent placement. She was ultimately treated by endovascular stenting of the aberrant right subclavian artery followed by thoracotomy and esophageal repair over a T-tube. This case report highlights the multidisciplinary approach needed to diagnose and manage such a devastating complication. It also emphasizes the need for imaging studies prior to stent deployment to delineate the vascular anatomy and rule out the possibility of such an anomaly in view of the growing popularity of esophageal stents, especially in the setting of a leak.

Treatment of large pharyngotracheal fistulas after laryngectomy by a novel customized pharyngeal stent

Persisting tracheoesophageal (TEF) and/or tracheopharyngeal (TPF) fistulas after laryngectomy are incessant problems that can lead to a tremendous loss of quality of life among patients. As soon as surgical options for closing fistulas become impractical, then alternative approaches to stent the fistulas gain significant value. Conventional stents seldom seal the entire fistula, might dislocate and tend to induce tissue proliferation and cause discomfort to the patient. On the basis of these side effects a novel customized pharyngeal stent has been developed to completely seal the fistula without dislocation and discomfort. The anatomic dimensions of the neopharynx in two patients were obtained by a silicone cast of the respective neopharynx and the stent was manufactured according to this anatomical model. The soft silicone edges of the stent match the pharyngeal anatomic structures and follow the changes of the base of the tongue during the process of swallowing. Nevertheless, the stents are rigid enough to remain in place. The reported two patients were able to subsist by themselves orally most of the time without any signs of leakage at all. One stent had to be explanted after 7 months due to an enlargement of the fistula. The second stent is still in place for 10 months up to now without any side effects.

Stent migration to the ileum: a potentially lethal complication after Montgomery salivary bypass tube placement for hypopharyngeal stenosis after laryngectomy

BACKGROUND

Montgomery salivary bypass tubes (MSBTs) have been used for decades in the treatment of stenoses and fistulae of the hypopharynx and the cervical esophagus. Generally, MSBT use is not associated with serious complications. Only a small number of cases with severe MSBT-associated complications have been reported in the literature.

METHODS AND RESULTS

We report for the first time an MSBT migration to the ileum in a laryngectomized patient who underwent surgical pharyngocutaneous fistula closure with MSBT placement. The MSBT was removed surgically via laparotomy. The patient died 15 days later due to sepsis associated with peritonitis.

CONCLUSION

To avoid potentially lethal complications associated with MSBT migration into the intestinal tract, we recommend secure fixation of the MSBT to a nasogastric tube.