[Interventional treatment of tracheoesophageal/bronchoesophageal fistulas]

Efficacy and risk factors of stent placement in the treatment of malignant tracheoesophageal fistula

Background

Due to the low incidence of malignant tracheoesophageal fistula and the paucity of relevant clinical studies, the benefits of stent implantation have not been well documented. It remains unclear which factors may affect fistula closure.

Methods

Between January 2015 and January 2021, 344 patients who were diagnosed with malignant tracheoesophageal fistula at Zhongda Hospital, Southeast University, were retrospectively enrolled. Demographic and clinical data were collected. Risk factors for fistula closure identified by univariate analysis were further analyzed using multivariable logistic regression.

Results

A total of 288 patients were analyzed in this study, of which 94 were treated conservatively, 170 were treated with an esophageal stent, and 24 were treated with a tracheal stent. Among them, the delta Karnofsky's performance status score values (after 2 weeks/before treatment [p = 0.0028], after 1 month/before treatment [p = 0.0103]) were significantly different between conservative and stent treatment. There was a significant reduction of pneumonia incidence in the stenting group (33.53%) compared to the conservative treatment group (77.05%) after one month (p <0.0001). In addition, the closure of fistulas was influenced by four independent risk factors: 1) treatment methods (p < 0.0001), 2) fistula size (p = 0.0003), 3) preoperative white blood cell count (p = 0.0042), and 4) preoperative Karnofsky's performance status score (p = 0.0001).

Conclusions

Stent implantation has become an effective method for treating malignant tracheoesophageal fistula compared to conservative treatment. Additionally, stent implantation, smaller fistula size, lower preoperative white blood cell count, and higher preoperative Karnofsky's performance status score suggest a better outcome.

A rare case of pulmonary mucormycosis and broncho-esophageal fistula in a patient with poorly controlled diabetes

Key Clinical Message

In patients with poorly controlled diabetes, early recognition of rare fungal infections like pulmonary mucormycosis, especially when presenting with unusual complications such as broncho-esophageal fistula, is critical. Prompt intervention with antifungal therapy and consideration for surgical debridement significantly impact outcomes. Multidisciplinary management is paramount for such complex cases.

Abstract

Mucormycosis is a rare fungal infection caused by the Mucorales. This infection is mostly observed among those with poorly controlled diabetes or immunodeficiency. The most common presentation of the infection among those with poorly controlled diabetes is rhino-orbit-cerebral involvement. In this case report, we provide the history and outcome of a rare case of pulmonary mucormycosis in a patient with poorly controlled diabetes who was simultaneously diagnosed with broncho-esophageal fistula. Our patient was a 32-year-old male with a history of poorly controlled diabetes. Over the months, he had complained of productive coughs and dyspnea, which had lately been joined by dysphagia. He also claimed to have lost considerable weight (10 kg) during the previous 3 months. Barium swallow showed an abnormal flow of contrast between the bronchus and esophagus, suggesting a broncho-esophageal fistula. Computed tomography of the thorax revealed a broncho-esophageal fistula between the left main bronchus (LMB) and esophagus. He had a bronchoscopy the next day, which revealed necrosis and a broncho-esophageal fistula in the LMB. A bronchial biopsy showed typical hyphae with necrotic tissue, indicating mucormycosis. The patient's antimycotic medication (liposomal amphotericin) was started and a prompt surgery consult was ordered. The patient, however, passed away from massive hemoptysis. We described a rare case of pulmonary mucormycosis with broncho-esophageal fistula in a patient with poorly controlled diabetes. The rarity of this combination highlights the associated diagnostic and treatment hurdles. Early detection, antifungal medication, as soon as possible surgical debridement of involved tissues, and a multidisciplinary approach could improve patient outcomes.

Bronchoesophageal fistula: An unusual manifestation of lung cancer

Bronchoesophageal fistula (BEF) is a rare condition caused by a fistulous connection between the bronchus and the esophagus. BEF can be acquired or congenital; congenital BEFs are rarely encountered in adults. Acquired BEF can be due to either a benign or a malignant process. Acquired BEF due to primary lung cancer is a life-threatening and usually a terminal complication. Unlike tracheoesophageal fistula, this condition is much rarer. Patients usually present with symptoms related to recurrent aspiration. Barium esophagogram is the initial diagnostic modality of choice. Treatment is primarily palliative. We are presenting a case of a bronchoesophageal fistula caused by non-small cell lung cancer that was successfully treated with concurrent chemoradiation therapy.

[Esophagotracheal and esophagobronchial fistulas]

Esophagobronchial and esophagotracheal fistulas are rare but complex diseases with a heterogeneous spectrum of underlying etiologies. Common causes are locally advanced tumors of the esophagus and larynx, traumatic perforation from the esophageal or tracheal side as well as postoperative fistulas. The management of esophagotracheal and esophagobronchial fistulas always involves different health care providers and in most cases patients require a multidisciplinary treatment on the intensive care unit. The therapeutic concept primarily depends on the underlying cause, localization and size of the fistula but decision making is also influenced by the severity of the course of sepsis and the extent of the respiratory dysfunction. Endoscopic management with esophageal and/or tracheobronchial stenting is the most common treatment. Surgical reconstructive procedures are predominantly reserved for patients with a treatment refractory fistula or a septic multiple organ failure. The prognosis is particularly influenced by the underlying disease.

Clinical outcomes and survival following placement of self-expandable metallic stents for central airway stenosis and fistula

Background

Self‐expandable metallic stent (SEMS) placement is an urgent procedure for patients with malignant central airway stenoses (CASs) and central airway fistulas (CAFs). The aim of this study was to determine the outcome and survival after SEMS placement in patients with malignant CASs and CAFs.

Methods

SEMSs were inserted into 20 patients with malignant CASs and four with malignant CAFs. Hospital records, the modified Medical Research Council dyspnea scale (mMRC) grade, performance status (PS), symptoms, procedure‐related complications and survival after placement were retrospectively reviewed.

Results

Spiral Z stents were inserted in nine patients, covered Ultraflex stents in 14, and a bare Ultraflex in one patient. After SEMS placement, 20 patients (83.3%) showed improvement in mMRC grade, 19 (79.2%) showed improvement in PS, and 21 (87.5%) showed improvement in symptoms. There were three patients whose stents migrated out of place, but there were no patients with obstructive granulation, infection, or mucous plugs. Median survival days after stent insertion was 98 days for CAS and 103 days for CAF, and mean survival days was 383 ± 707 days for CAS and 93 ± 33 days for CAF. Two patients with CAS by malignant lymphoma and thymic cancer survived more than six years because they were also treated with efficient therapies. The five‐year survival rate after stent insertion was 7.7%.

Conclusions

SEMS placement for CAS and CAF is associated with improvement in mMRC grade, PS and symptoms in 87.5% of patients. Patients with a malignant CAS are usually terminal, but the possibility of increasing survival rate will become a reality with new efficient therapies.

Key points

Significant findings of the study

Reasonable clinical outcomes and improved survival of patients following SEMS placement for thoracic malignancy with central airway stenosis and fistula.

What this study adds

The possibility of increasing survival rate will become a reality with new efficient therapies.