Malignant esophagorespiratory fistula: management options and survival

Airway Esophageal Fistula

Acquired tracheoesophageal fistulas (TEFs) are rare pathologic connections between the trachea and esophagus. Esophageal and tracheal stenting have been increasingly and safely utilized in management of TEFs, but surgical repair remains the most definitive treatment. Surgical approach to treating TEFs depends on its location, but principles include division and closure of the fistula tracts and insertion of a muscle flap in between the repairs to buttress and prevent recurrence. Advances in diagnostic tools, endoscopic and surgical methods, and intensive care have led to significantly improved outcomes in the management of acquired TEFs.

Establishment of acquired tracheoesophageal fistula using a modified magnetic compression technique in rabbits and its postmodeling evaluation

BACKGROUND

Previous studies have validated the efficacy of both magnetic compression and surgical techniques in creating rabbit tracheoesophageal fistula (TEF) models. Magnetic compression achieves a 100% success rate but requires more time, while surgery, though less frequently successful, offers rapid model establishment and technical maturity in larger animal models.

AIM

To determine the optimal approach for rabbit disease modeling and refine the process.

METHODS

TEF models were created in 12 rabbits using both the modified magnetic compression technique and surgery. Comparisons of the time to model establishment, success rate, food and water intake, weight changes, activity levels, bronchoscopy findings, white blood cell counts, and biopsies were performed. In response to the failures encountered during modified magnetic compression modeling, we increased the sample size to 15 rabbit models and assessed the repeatability and stability of the models, comparing them with the original magnetic compression technique.

RESULTS

The modified magnetic compression technique achieved a 66.7% success rate, whereas the success rate of the surgery technique was 33.3%. Surviving surgical rabbits might not meet subsequent experimental requirements due to TEF-related inflammation. In the modified magnetic compression group, one rabbit died, possibly due to magnet corrosion, and another died from tracheal magnet obstruction. Similar events occurred during the second round of modified magnetic compression modeling, with one rabbit possibly succumbing to aggravated lung infection. The operation time of the first round of modified magnetic compression was 3.2 ± 0.6 min, which was significantly reduced to 2.1 ± 0.4 min in the second round, compared to both the first round and that of the original technique.

CONCLUSION

The modified magnetic compression technique exhibits lower stress responses, a simple procedure, a high success rate, and lower modeling costs, making it a more appropriate choice for constructing TEF models in rabbits.

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

Efficacy and Safety of Self-Expandable Metallic Stent Placement for Malignant Esophageal Fistula

Patients with malignant esophageal fistulas often experience dysphagia and infection, resulting in poor prognoses. Self-expandable metallic stent (SEMS) placement is a palliative treatment option; however, its efficacy and safety are unclear. We aimed to determine the efficacy and safety of SEMS placement for malignant esophageal fistulas. We retrospectively investigated patients who underwent SEMS placement for malignant esophageal fistulas between 2013 and 2022 at the Cancer Institute Hospital. Dysphagia scores (DSs) before and after SEMS placement, adverse events, and overall survival from SEMS placement until death were evaluated. A total of 17 patients underwent SEMS placement, including 12 and 5 patients with esophageal and lung cancers, respectively. Prior treatments included chemoradiotherapy (n = 11), radiotherapy (n = 4), and chemotherapy (n = 4); two patients underwent palliative radiotherapy after chemotherapy. All procedures were technically successful. After SEMS placement, 14 (82.4%) patients were able to consume semisolid or solid food (DS ≤ 2). Major adverse events were encountered in only one case. The median survival time after SEMS placement was 71 days (range 17-247 days). SEMS placement allowed most patients to resume oral intake with a low rate of major adverse events. SEMS placement is a reasonable palliative treatment option for patients with malignant fistulas who have poor prognoses.

Diagnosis and Management of a Massive Eight-Centimeter Acquired Tracheoesophageal Fistula

Here, we present the case of a 61-year-old veteran Hispanic male with recurrent aspiration pneumonitis, aerophagia, tympanic abdominal bloating, and a positive Ono's sign; symptoms present were secondary to diagnosed tracheoesophageal fistulas (TEFs). TEFs are abnormal connections between the esophagus and the trachea. In adult cases, several risk factors have been identified for acquired cases, which include infection, trauma, and cancer. Diagnosis of TEF can be challenging and, in most cases, requires high suspicion. Currently, there are no established guidelines for diagnosing and managing TEF. Clinical assessment and various imaging techniques are essential in the diagnostic process. This article will discuss the etiology, clinical presentation, diagnostic approaches, and management options for acquired TEFs.

Comparison of Short-term Outcomes Between Esophageal Bypass Surgery and Self-expanding Stent Insertion in Esophageal Cancer: A Propensity Score-matched Analysis Using a Large-scale Inpatient Database

BACKGROUND

Advanced esophageal cancer is occasionally accompanied by difficulty swallowing owing to esophageal stenosis or tracheoesophageal fistula formation. Esophageal bypass surgery and stent insertion are considered feasible palliative management options. The aim of this study was to evaluate the short-term outcomes of these palliative treatments.

MATERIALS AND METHODS

Patient data were obtained from a large-scale inpatient database of 42 National University Hospitals in Japan. Patients with advanced esophageal cancer who underwent esophageal bypass surgery or stent insertion between April 2016 and March 2021 were included in this study. One-to-one propensity score matching of patients who underwent bypass surgery or stent insertion was performed. The primary outcomes were time to diet resumption and length of hospital stay after surgery. The secondary outcome was the incidence of postoperative complications.

RESULTS

In 43 propensity score-matched pairs, the incidence of postoperative respiratory complications was significantly higher in the bypass group than in the stent group (32.6% vs. 9.3%, P = 0.008). Postoperative length of hospital stay was longer in the bypass group than in the stent group (24 vs. 10 d, P < 0.001). Logistic regression analysis revealed that stent insertion was associated with a decreased risk of respiratory complications (odds ratio 0.077, P < 0.007). Among patients who underwent the interventions (bypass surgery or stent insertion) and subsequently underwent anticancer therapy (chemotherapy/radiotherapy) during hospitalization, the interval between the intervention and anticancer therapy was longer in the bypass group than in the stent group (25 vs. 7 d, P = 0.003).

CONCLUSIONS

Esophageal stent insertion provides better short-term outcomes than bypass surgery in patients with advanced unresectable esophageal cancer.

Case report: Surgical repair of a large tracheo-esophageal fistula in a patient with post-transplant esophageal lymphoproliferative disorder

Introduction and importance

The management of large malignant tracheo-esophageal fistulas (TEF) is not standardized. Herein, we report a case with a malignant TEF associated with esophageal post-transplant lymphoproliferative disorder (PTLD) for whom we successfully performed a surgical repair. This contributes to the knowledge on how to treat large acquired malignant TEFs.

Case presentation

A 69-year old male presented with a one-week history of fever, productive cough and bilateral coarse crackles. In addition, he described a weight loss of 10 kg during the past three months. The patient's history included a kidney transplantation twenty years ago. Esophagogastroduodenoscopy with a biopsy of the esophagus was performed nine days before. Histopathology showed a PTLD of diffuse large B-cell lymphoma subtype. Subsequent diagnostics revealed a progressive TEF (approx. 2.0 × 1.5 cm) 3.0 cm above the carina. PET-CT scan showed an esophagus with slight tracer uptake in the middle third (approx. 11.5 cm length, SUV max 7.4). After decision against stenting, transthoracic subtotal esophagectomy with closure of the tracheal mouth of the fistula by a pedicled flap was performed. PTLD was treated with prednisone and rituximab. Tumor progression (brain metastasis) led to death 95 days after surgery.

Clinical discussion

The treatment of a malignant TEF is complex and personalized while both the consequences of the esophago-tracheal connection and those of the underlying responsible diagnosis have to be considered concurrently. In this case, we considered surgery as the best treatment option due to a relatively good prognosis of the underlying diagnosis (PTLD) and a large fistula. Esophageal or dual stenting, the treatment of choice for small malignant TEF, would have been associated with a high risk of failure due to the wide trachea, extensively dilated esophagus, proximal location and large diameter of the fistula.

Conclusion

Surgery can be considered for patients with a large acquired malignant TEF and positive long-term prognosis of the underlying diagnosis. Due to the complexity of TEF management, immediate pre-operative multidisciplinary discussion is advised.

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Surgical repair of a large malignant tracheo-esophageal fistula

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Immediate pre-operative multidisciplinary discussion is needed for large malignant trachea-esophageal fistulas.

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Esophageal post-transplant lymphoproliferative disorder (PTLD) of diffuse large B-cell lymphoma (DLBCL) subtype

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Esophagectomy and closure of the trachea by a pedicled deepithelized muscle flap

Use of airway stents to treat malignant tracheobronchial fistulas: Our six-year experience

BACKGROUND

This study aims to investigate the indications, safety, complications, and long-term outcomes of airway stenting in the treatment of malignant tracheobronchial fistulas.

METHODS

The medical records of a total of 34 patients (24 males, 10 females; mean age: 55.4+13 years; range, 23 to 76 years) with malignant tracheobronchial fistulas treated with airway stenting between February 2014 and August 2020 were retrospectively analyzed. Data including demographic features, diagnosis, symptoms, treatment, complications and outcomes were recorded.

RESULTS

Thirty-eight airway stents were inserted in 34 patients with malignant tracheobronchial fistulas, including 19 patients with malignant tracheobronchial esophageal fistulas and 15 patients with bronchopleural fistulas. The clinical success and the technical success rates were 91% and 100%, respectively. No perioperative death or severe complications occurred. Chronic complications (>24 h) occurred in eight (23%) patients with malignant tracheobronchial fistula. Median follow-up was 3.5 (range, 1.4 to 5.5) months in patients with malignant tracheobronchial esophageal fistulas and 18 (range, 9.5 to 26.5) months in patients with bronchopleural fistulas. Mortality rates were 79% and 61%, respectively.

CONCLUSION

Airway stent insertion provides a secure and effective treatment for patients with malignant tracheobronchial fistulas.

Computed Tomography Imaging of Iatrogenic Esophageal Injuries

ABSTRACT

Knowledge of iatrogenic esophageal injuries is important given the variety of etiologies, including medical instrumentation (eg, endoscopes), radiotherapy, and anticoagulation. The clinical presentation and imaging findings of esophageal injuries depend on the mechanism and location of the injury. Imaging modalities commonly used for the evaluation of esophageal injuries include esophagram and computed tomography. Esophageal injuries should be considered in patients with acute chest symptoms. Recognizing an unsuspected esophageal injury on imaging can be critical to reaching the correct diagnosis given their nonspecific symptomatology. This review article highlights various iatrogenic esophageal injuries and their appearance on computed tomography imaging.

Tailored endoscopic treatment of tracheo-oesophageal fistula using preoperative holographic assessment and a cardiac septal occluder

Devices originally designed for closure of cardiac septal defects have also been proposed for the treatment of acquired tracheo-oesophageal fistula (TOF). Choosing the right occluder device to match TOF size and shape is essential for a tailored treatment. We report the successful endoscopic closure of a post-radiotherapy TOF using preprocedural CT scan with holographic three-dimensional reconstruction and an Amplatzer atrial septal device. Complete TOF sealing was achieved with resolution of respiratory symptoms, and the patient was maintaining his ability to eat at 4-month follow-up.

Acquired Tracheoesophageal Fistulas: A Case Report and Review of Diagnostic and Management Challenges

Acquired, nonmalignant tracheoesophageal fistulas (TEFs) often occur in the setting of prolonged use of endotracheal or tracheostomy tubes due to trauma and erosion of the tracheal wall inflicted by tube cuffs or direct tracheal contact. In this report, we present a patient with a tracheostomy who presented with recurrent aspiration pneumonia and was found to have a large TEF that was difficult to treat. We also discuss the diagnostic and management challenges concerning TEFs. TEFs, especially if large, lead to recurrent aspiration pneumonia and can be challenging to manage. Definitive management of TEFs involves surgical repair; meanwhile, endoscopic or bronchoscopic stenting to bypass the fistula can be performed. The fistula location, size, and concurrent positive pressure ventilation make its treatment challenging in those with chronic ventilatory dependence. Early recognition and multidisciplinary management involving gastroenterologists, interventional pulmonologists, and thoracic surgeons are necessary to decide on the best treatment strategy.

Management of Esophageal Cancer-Associated Respiratory–Digestive Tract Fistulas

Respiratory–digestive tract fistulas are fatal complications that occur in esophageal cancer treatment. Interdisciplinary treatment strategies are still evolving, especially in anatomical treatment stratification. Thus, this study aims to evaluate general therapeutic strategies for this rare condition. Medical records were reviewed for esophageal cancer-associated respiratory–digestive tract fistula patients treated between January 2008 and September 2021. Fistulas were classified according to being surgery- and tumor-associated. Treatment strategies, clinical success, and survival were analyzed. A total of 51 patients were identified: 28 had tumor-associated fistulas and 23 surgery-associated fistulas. Risk factors for fistula development such as radiation (OR = 0.290, p = 0.64) or stent implantation (OR = 1.917, p = 0.84) did not correlate with lack of symptom control for RDF patients. In contrast, advanced lymph node metastasis as another risk factor was associated with persistent symptoms after treatment for RDF patients (OR = 0.611, p = 0.01). Clinical success significantly correlated with bilateral fistula repair in surgery-associated fistulas (p = 0.01), while tumor-associated fistulas benefited the most from non-surgical (p = 0.04) or combined surgical and non-surgical intervention (p = 0.04) and a bilateral fistula repair (p = 0.02) in terms of overall survival. The therapeutic strategy should aim for bilateral fistula closure. A multidisciplinary, stepwise approach might have the best chance for restoration or symptom control with optimized overall survival in selected patients.

A Complicated Parenchymal-Esophageal Fistula in Non-Small Cell Lung Cancer

Respiratory digestive fistula (RDF) is an abnormal communication between the airway and the digestive tract. Only 3-11% of RDF communications are parenchymal-esophageal fistulas. We present a case of a 58-year-old male who presented to the emergency department with dysphagia and cough after swallowing. He was diagnosed with stage III/B non-small cell lung cancer. The patient was previously treated with chemotherapy, radiation, and immunotherapy. Computed tomography (CT) scan of the chest with contrast showed a chronic cavitary right upper lobe lesion in the previously treated malignancy area. New right paratracheal adenopathy, right esophageal wall thickening, and bilateral lung infiltrates were also shown. Upper endoscopy with bronchoscopy and endobronchial ultrasound (EBUS) was done to evaluate mediastinal lymphadenopathy as well as dysphagia. A tract was found extending from the right lung cavity into the esophagus through the mediastinum. Esophagoscopy was subsequently performed, and a fistula was observed on the right wall of the mid-esophagus. The defect was favorable for clipping, which was successfully closed with an 11/6 traumatic over the scope clip, followed by a fully covered esophageal stent. The patient’s respiratory and gastrointestinal symptoms improved after the procedure. Follow-up barium swallow was negative for any esophageal leak. At three-month follow-up, the patient was free of recurrent pulmonary and gastrointestinal symptoms that he presented with. Palliative therapy is the targeted therapy for RDF management. RDF is either managed conservatively or with radiation, chemotherapy, or surgery to obliterate the connection. Surgical correction usually is not an option since patients typically have a poor functional status at the time of diagnosis. Considering the survival and recurrence rate medical intervention is the mainstay of treatment. Parallel dual (esophageal-bronchial) stenting has been proven to provide the best outcomes. Self-expanding metal stents (SEMS), either covered or partially covered, are used extensively to manage malignant RDF.

High-Dose Chemotherapy With Autologous Stem Cell Transplantation in a Case of Refractory Peripheral T Cell Lymphoma With Tracheoesophageal Fistula: A Case Report

A 46-year-old woman with a sore throat was diagnosed with anaplastic lymphoma kinase-negative anaplastic large cell lymphoma that had spread from the piriform fossa to the cervical esophagus. Tracheoesophageal fistula developed after induction chemotherapy. Because conservative repair was not applicable, intensified chemotherapy, including autologous stem cell transplantation was performed with the fistula remaining open. Laryngopharyngectomy and cervical esophagectomy were performed 6 months after transplantation. The optimal strategy for refractory lymphoma with active tracheoesophageal fistula remains undetermined. To the best of our knowledge, this is the first report describing the successful treatment of a patient with tracheoesophageal fistula who received high-dose chemotherapy supported by autologous stem cell transplantation.

Imaging of therapeutic airway interventions in thoracic oncology

Tracheobronchial obstruction, haemoptysis, and airway fistulas caused by airway involvement by primary or metastatic malignancies may result in dyspnoea, wheezing, stridor, hypoxaemia, and obstructive atelectasis or pneumonia, and can lead to life-threatening respiratory failure if untreated. Complex minimally invasive endobronchial interventions are being used increasingly to treat cancer patients with tracheobronchial conditions with curative or, most often, palliative intent, to improve symptoms and quality of life. The selection of the appropriate treatment strategy depends on multiple factors, including tumour characteristics, whether the lesion is predominately endobronchial, shows extrinsic compression, or a combination of both, the patient's clinical status, the urgency of the clinical scenario, physician expertise, and availability of tools. Pre-procedure multidetector computed tomography (MDCT) imaging can aid in the most appropriate selection of bronchoscopic treatment. Follow-up imaging is invaluable for the early recognition and management of any potential complication. This article reviews the most commonly used endobronchial procedures in the oncological setting and illustrates the role of MDCT in planning, assisting, and follow-up of endobronchial therapeutic procedures.

Positron Emission Tomography/Computed Tomography Alert Finding in an Esophageal Cancer Patient

Emergency pathologies often accompany malignancies. We herein report a case of pulmonary abscess in a patient with esophageal cancer which was depicted during the F-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) staging study. The patient's history of recent dilatation of the cancer stenosis in adjunct to the previous CT lung imaging, which was normal, made evident the diagnosis of the pulmonary abscess due to the perforation of the esophageal neoplasm. This life-threatening condition was promptly referred and successfully managed.

Management of tracheo-oesophageal fistula in adults

Tracheo-oesophageal fistula (TOF) is a pathological connection between the trachea and the oesophagus that is associated with various underlying conditions including malignancies, infections, inhalation injuries and traumatic damage. As the condition spans multiple organ systems with varying aetiologies and acuities, TOF poses unique diagnostic and management challenges to pulmonologists, gastroenterologists and thoracic surgeons alike. Although stents have been a cornerstone in the management of TOF, there exists a large gap in our understanding of their efficacy and precise methodology, making stenting procedure both art and science. TOFs relating to underlying oesophageal or tracheal malignancies require advanced understanding of the airway and digestive tract anatomy, dimensions of the fistula, stent characteristics and types, and the interplay between the oesophageal stent and the airway stent if dual stenting procedure is elected. In this review article, we review the most up-to-date data on risk factors, clinical manifestations, diagnostic approaches, management methods and prognosis. Consequently, this article serves to evaluate current therapeutic strategies and the future directions in the areas of 3D-printed stents, over-the-scope clipping systems, tissue matrices and atrial septal closure devices.

Regenerative medicine approaches for the management of respiratory tract fistulas

Respiratory tract fistulas (or fistulae) are abnormal communications between the respiratory system and the digestive tract or the adjacent organs. The origin can be congenital or, more frequently, iatrogenic and the clinical presentation is heterogeneous. Respiratory tract fistulas can lead to severely reduced health-related quality of life and short survival. Therapy mainly relies on endoscopic surgical interventions but patients often require prolonged hospitalization and may develop complications. Therefore, more conservative regenerative medicine approaches, mainly based on lipotransfer, have also been investigated. Adipose tissue can be delivered either as unprocessed tissue, or after enzymatic treatment to derive the cellular stromal vascular fraction. In the current narrative review, we provide an overview of the main tissue/cell-based clinical studies for the management of various types of respiratory tract fistulas or injuries. Clinical experience is limited, as most of the studies were performed on a small number of patients. Albeit a conclusive proof of efficacy cannot be drawn, the reviewed studies suggest that grafting of adipose tissue-derived material may represent a minimally invasive and conservative treatment option, alternative to more aggressive surgical procedures. Knowledge on safety and tolerability acquired in prior studies can lead to the design of future, larger trials that may exploit innovative procedures for tissue processing to further improve the clinical outcome.

Bronchial Fistula: Rare Complication of Treatment with Anlotinib

BACKGROUND

Anlotinib is a newly developed small molecule multiple receptor tyrosine kinase (RTK) inhibitor that was approved for the treatment of patients with lung cancer in China. We aim to report 3 cases of rare complication of anlotinib-bronchial fistula (BF) during the treatment of lung cancer patients and summarize the possible causes.

METHODS

We collected three patients who developed BF due to anlotinib treatment, and conducted a search of Medline and PubMed for medical literature published between 2018 and 2020 using the following search terms: "anlotinib," "lung cancer," and "fistula."

RESULTS

Our literature search produced two case reports (three patients) which, in addition to our three patients. We collated the patients' clinical characteristics including demographic information, cancer type, imaging features, treatment received, risk factors for anlotinib related BF, and treatment-related outcomes. The six patients shared some common characteristics: advanced age, male, concurrent infection symptoms, diabetes mellitus (DM), advanced squamous cell and small cell lung cancers, centrally located tumors, tumor measuring ≥5 cm in longest diameter, and newly formed tumor cavitation after multi-line treatment especially after receiving radiotherapy. Fistula types included broncho-pericardial fistula, broncho-pleural fistula, and esophago-tracheobronchial fistula. Six patients all died within 6 months.

CONCLUSIONS

Although anlotinib is relatively safe, it is still necessary to pay attention to the occurrence of BF, a rare treatment side effect that threatens the quality of life and overall survival of patients. Anlotinib, therefore, requires selective use and close observation of high-risk patients.

Malignant esophagorespiratory fistulas: a comparative effectiveness survival analysis

OBJECTIVES

To analyse the survival of patients with malignant esophagorespiratory fistulas (ERF) and perform a comparative effectiveness analysis of ERF-directed interventions.

METHODS

Fifty-five patients met our inclusion criteria, and data on ERF-directed interventions (stent placement, surgical repair and best supportive care) and their outcomes, along with clinical and treatment details, were recorded. The primary endpoints were overall survival (OS) and survival after developing ERF (F-OS).

RESULTS

The median OS and F-OS for the entire cohort was 299 days (SE=23.2) and 123 days (SE=11.63), respectively. On univariable analysis, the American Joint Committee on Cancer (AJCC) stage (I-III vs IV) influenced both OS (403 vs 171 days; p=0.006) and F-OS (129 vs 67 days; p=0.034). Proximal location of ERF influenced OS favourably (494 vs 285 days; p=0.021), whereas patients developing ERF late in their disease course experienced inferior F-OS (96 vs 232 days; p=0.03). On multivariable analysis, the AJCC stage (IV vs I-III, HR=3.03 (1.41-6.50)), time to developing ERF from diagnosis (greater than vs within 3 months, HR=5.82 (1.84-18.36)) and location of ERF (distal vs proximal, HR=2.47 (1.14-5.34)) had a significant impact on F-OS. The comparative efficacy (OS and F-OS) of best supportive care was statistically equivalent to any intervention irrespective of AJCC stage and success/failure of initial or subsequent intervention(s).

CONCLUSIONS

The survival of patients with ERF is dismal, and our analysis suggests that best supportive care results in equivalent OS and F-OS when compared with any intervention.

Self-expanding metallic Y-stent compared to silicone Y-stent for malignant lesions of the main carina: A single center retrospective study

BACKGROUND

Bifurcation stents are often required in patients with malignant airway obstruction or fistulization involving the main carina. The silicone Y stent is the most used but remains challenging to place. The self-expanding metallic Y (SEM) stent appears easy to use. The objective is to report the feasibility, efficacy, and tolerance of SEM Y stent compared to silicone Y stent in patients with malignant tumors involving the main carina.

PATIENTS AND METHODS

This retrospective single center study was performed between May 2004 and May 2017. All patients with malignant carina involvement treated with a bronchial Y stent were included.

RESULTS

Forty silicone Y stents and 38 SEM Y stents were placed. Seven stenting placements failed in the silicone Y group but none in the SEM Y stent group (P=0.008). The median duration of the procedure was 80min (25-210) in the silicone Y group and.50min (25-110min) in the SEM Y group (P=0.001). There was no significant difference in terms of early or late complications between the 2 groups. Nine silicone Y stents (26.5%) and 7 SEM Y stents (18.4%) were removed (P=0.4). The median survival time following stent insertion was 171 days (Interquartile range (IQR): 53-379) in the silicone Y group and 104 days (IQR: 53-230) in the SEM Y group.

CONCLUSION

If silicone Y stent remains the best solution for benign obstruction, SEM Y stent seems to be an easy alternative with no difference in terms of complication or ablation for malignant lesions involving the main carina.

Risk Factors for Esophageal Fistula in Esophageal Cancer Patients Treated with Radiotherapy: A Systematic Review and Meta-Analysis

<b><i>Objective:</i></b> Esophageal fistula is a critical and fatal complication of esophageal cancer. The aim of this meta-analysis was to explore the risk factors for esophageal perforation in esophageal cancer patients treated with radiotherapy. <b><i>Methods:</i></b> Data from the PubMed and Embase databases were retrieved for clinical research published between 1990 and 2018. The Newcastle-Ottawa Scale was used to evaluate the quality of the articles. A meta-analysis was performed using the RevMan 5.3 software provided by the Cochrane Collaboration Network. <b><i>Results:</i></b> Seventeen articles were eligible for the meta-analysis. In these articles, over 35 risk factors for esophageal fistula formation were described and 17 risk factors were analyzed. Significant differences in the odds of developing an esophageal perforation were found with regard to age (OR 2.34, 95% CI 1.08–5.03, <i>p</i> = 0.001), ulcerative type (OR 2.72, 95% CI 1.43–5.16, <i>p</i> = 0.002), histology (OR 4.16, 95% CI 1.14–15.12, <i>p</i> = 0.03), T stage (OR 2.66, 95% CI 1.44–4.91, <i>p</i> = 0.002), short-term response (OR 2.21, 95% CI 1.06–4.62, <i>p</i> = 0.03), chemotherapy regimen (OR 2.80, 95% CI 1.38–5.68, <i>p</i> = 0.005), and stenosis (OR 2.00, 95% CI 1.03–3.89, <i>p</i> = 0.04). <b><i>Conclusions:</i></b> An age of &#x3c;60–65 years, ulcerative type, squamous cell cancer, T4 stage, incomplete response, fluorouracil-based regimen, and stenosis were associated with an increased risk of esophageal fistula during or after radiotherapy. However, further, large-scale prospective studies are needed to establish the validity of this associ­ation.

[Interventional treatment of tracheoesophageal/bronchoesophageal fistulas]

A tracheoesophageal fistula is the formation of an abnormal communication between the airway and the esophagus. Acquired tracheoesophageal fistulas can be benign or malignant. The management is either surgical or endoscopic depending on the etiology, size and anatomy of the fistula as well as on the patient's performance status. The interventional treatment of choice is endoscopic stent implantation. In general, tracheoesophageal fistulas in patients with benign conditions are managed surgically. If the patient is unfit for surgery silicone stents should be used because they can be more easily removed after a longer indwelling time compared to metal stents. Malignant fistulas are associated with very limited life expectancy of only a few weeks or months. In this situation fully covered self-expandable metal stents (FC-SEMS) are recommended, whereas surgical treatment approaches can only be considered in individual cases. Depending on the location of the fistula and the presence of an airway stenosis, tracheal stenting, esophageal stenting or parallel stenting of the trachea and the esophagus is carried out. Successful stent placement leads to immediate palliation of symptoms, such as cough or aspiration and results in a higher quality of life. Potential complications are stent migration, bleeding of the upper gastrointestinal tract, arrosion of neighboring organs and vessels with esophageal stents as well as secretion retention and obstruction with displacement of the airway with tracheobronchial stents.

Drainage Tubeless (DRESS) Bypass Surgery as the Best Palliative Care for Unresectable Thoracic Esophageal Cancer with and without Esophago-Respiratory Fistula

Approximately half of the patients with esophageal cancer are diagnosed at an advanced stage with inoperable disease. The technique of bypass surgery, which is one of the palliative procedures for esophageal cancer, usually requires the insertion of a drainage tube for clearing secretions from the blind remnant esophagus. Since the artificial drainage tube is sometimes problematic for the patient after discharge from the hospital, drainage tubeless (DRESS) surgery might be preferable. The authors demonstrated the utility of DRESS bypass surgery by adding esophagostomy in the right supraclavicular region in three patients with unresectable esophageal cancer with and without esophago-respiratory fistula. All patients had been able to take per-orally and discharged the hospital. Two of three patients are alive with per-oral intake at 1 year later. This DRESS bypass surgery technique, which has not hardly reported in the literature, could release the patients from the tube trouble after the discharge from the hospital and give the patients the better quality of life.

Clinical outcomes of radiation therapy for clinical T4b oesophageal cancer with airway invasion

Background

Oesophageal cancer with airway invasion presents a challenge for therapy and often has serious complications. We analysed the clinical outcomes of radiation therapy (RT) in patients with clinical T4b oesophageal cancer with airway invasion.

Methods

We retrospectively reviewed the medical records of 73 patients with oesophageal cancer who had clinical T4 disease and who received RT between January 1994 and June 2017. Among them, 47 patients with clinical T4b disease with airway invasion were included in this study; 31 had gross invasion on bronchoscopy and 16 had extrinsic compression with mucosal change. We investigated the survival outcomes, clinical courses, and toxicities.

Results

The median survival (MS) time was 9 months. The 1- and 2-year overall survival (OS) rates were 41.4 and 27.4%, respectively. The MS times for patients treated with curative or palliative aims were 15 and 4 months, respectively (p = 0.001). Seven patients (14.9%) had fistulae at diagnosis; after RT, three had no change in size, three closed, and one had increased. Newly developed oesophageal fistulae after treatment were observed in 13 patients (27.7%). The median time to a newly developed fistula was 3 months (range, 1–15). Among them, a fistula was closed in only one patient. Death from aspiration pneumonia occurred in one patient who had a fistula at diagnosis and in nine patients who newly developed fistulae after treatment. Severe oesophageal bleeding causing death occurred in two patients. Patients with gross invasion on bronchoscopy had a higher risk of developing a fistula than did patients with mucosal change (37.5% vs. 25.0%, respectively).

Conclusions

Even for clinical T4b disease with airway invasion, RT with a curative aim showed acceptable survival outcomes in patients with good performance status and no distant metastasis at initial diagnosis. However, the risk of fistula development associated with fatal events remains high. Further study is warranted to decrease the risks of treatment and improve clinical outcomes.

Trial registration

Retrospectively registered.

Bronchoscopic advances in the management of aerodigestive fistulas

Malignant aerodigestive fistula (ADF) is an uncommon condition complicating thoracic malignancies. It results in increased morbidity and mortality and warrants therapeutic intervention. The management approach depends on symptoms, configuration, location, and extent of the fistula. This article will discuss the therapeutic considerations in the management of ADF.

Management of Malignant Tracheoesophageal Fistula

When a malignant fistula develops between esophagus and trachea, the underlying cancer is invariably incurable whether the primary site is in the esophagus or in the trachea. The frequent complication of this fistula is nonresolving aspiration pneumonia, either from ingestion or from backward flow of gastric contents into the esophagus. Pulmonary sepsis causes fatality in about 6 to 12 weeks if aspiration through the fistula is not treated quickly. The fistula develops in untreated esophageal cancer in approximately 5% to 15% of cases, lung cancer in less than 1% of cases, and tracheal cancer in 14.75% of cases.

An Unusual Case of an Acquired Esophageal-pulmonary Fistula Caused by Hodgkin Lymphoma

Bronchoesophageal and tracheoesophageal fistulas are an uncommon but well-documented complication of Hodgkin lymphoma (HL). To our knowledge, a fistula directly connecting the esophagus with the lung (esophageal-pulmonary fistula) and resulting from HL has not been reported in the literature. We present a case of HL complicated with an esophageal-pulmonary fistula. The early recognition and treatment of an esophageal-pulmonary fistula in patients with HL are imperative since, with appropriate treatment, HL complicated with an aero-esophageal fistula has the same prognosis as those without one, unlike the dismal prognosis in esophageal and lung cancer. Endoscopic esophageal stenting followed by chemotherapy is the preferred treatment approach. This leads to the healing of the fistula and the prolongation of patient survival.

Clinical application of oral meglumine diatrizoate esophagogram in screening esophageal fistula during radiotherapy for esophageal cancer

INTRODUCTION

Esophageal fistula is a serious and common complication of radiotherapy for esophageal cancer. Therefore, early diagnosis and treatment is necessary. Because of side effect of barium esophagography, it cannot be used to screening esophageal fistula during radiotherapy. Meglumine diatrizoate is an ionic contrast agent, its adverse reactions were rarely seen when it was used in the body cavity. The purpose of this trial is identified the sensitivity and specificity of oral meglumine diatrizoate in an esophagogram for screening esophageal fistula during radiotherapy.

METHODS/DESIGN

This trial was a prospective, multicenter, diagnostic clinical trial. A total of 105 patients with esophageal cancer will swallowed meglumine diatrizoate and underwent a radiographic examination weekly during radiotherapy, medical personnel observed the esophageal lesions to determine whether an esophageal fistula formed. If an esophageal fistula was observed, esophagofiberoscopy and/or computer tomography was used to further confirm the diagnosis. And the sensitivity and specificity of meglumine diatrizoate should be calculated for screening esophageal fistula during radiotherapy.

DISCUSSION

To our knowledge, this study protocol is the first to identify the sensitivity and specificity of oral meglumine diatrizoate in an esophagogram for screening esophageal fistula during radiotherapy. If oral meglumine diatrizoate can be used to screening esophageal fistula, more patients will benefit from early detection and treatment.

Esophagorespiratory Fistulas: Survival and Outcomes of Treatment

GOAL

The purpose of this study was to characterize outcomes of esophagorespiratory fistulas (ERF) by etiology and initial treatment strategy.

BACKGROUND

ERF is a morbid condition for which optimal treatment strategies and outcomes are still in evolution.

STUDY

Medical records and images were reviewed for all patients diagnosed with ERF at Mayo Clinic in Rochester, MN, between September 1, 2001 and January 1, 2012. Fistulas were classified as malignant or benign. Treatment strategies were classified as surgical or nonsurgical (typically esophageal stent placement). Technical and clinical success, survival, and survival free of second intervention were assessed.

RESULTS

A total of 123 patients with acquired ERF were identified, of whom 65 (53%) were malignant and 58 (47%) benign. Initial treatment strategy was nonsurgical in 88 (72%) patients and surgical in 35 (28%); lower Charlson comorbidity scores were associated with increased likelihood of surgery. Technical and clinical success was seen in a majority of patients treated both surgically and nonsurgically. Patients with malignant ERF treated surgically survived longer than patients undergoing nonsurgical treatment (hazard ratio=5.6, P=0.005). In contrast, those with benign ERF had similar overall survival regardless of whether they received initial surgical or nonsurgical treatment; reintervention was more common in those who underwent nonsurgical treatment (hazard ratio=2.3, P=0.03).

CONCLUSIONS

We conclude that survival in malignant ERF is better with surgical intervention in selected patients. Surgical and nonsurgical techniques achieve similar survival in benign ERF, but reintervention is more common in those treated endoscopically.

Acquired Adult Aerodigestive Fistula: Classification and Management

BACKGROUND

Acquired aerodigestive fistulae (ADF) are rare, but associated with a high mortality rate. We present our experience of the diagnosis, management and outcomes of patients with ADFs treated at a tertiary centre. Utilising our findings, we propose an anatomical classification system, demonstrating how specific features of an ADF may determine management.

METHODS

A clinical database was searched and 48 patients with an ADF were identified. A classification system was developed based on anatomical location of the ADF and differences in clinico-pathological features based on this categorisation were performed, with the chi-squared test used for inferential analyses and Kaplan-Meier curves with log-rank test to assess survival.

RESULTS

Twenty (41.6%) patients developed an ADF secondary to malignancy, with previous radiotherapy (18.7%), post-operative anastomotic dehiscence and endotherapy (14.6% each) representing other causes. Thirty-one patients were managed with tracheal and/or oesophageal stents and eight underwent surgical repair. The classification system demonstrated benign causes of ADF were either proximally or distally sited, whilst a malignant cause resulted in mid-tracheal fistulae (p = 0.001), with the latter associated with poorer survival. ADFs over 20 mm in size were associated with poor survival (p = 0.011), as was the use of previous radiotherapy. Proximal and distal ADFs were associated with improved survival (p = 0.006), as were those patients managed surgically (p = 0.001).

CONCLUSION

By classifying ADFs, we have demonstrated that anatomical location correlates with the size, history of malignancy, previous radiotherapy and aetiology of ADF, which can affect management. The proposed classification system will aid in formulating multi-modality individualised treatment plans.

Late Onset Chemo/Radiation Induced Tracheoesophageal Fistula in Squamous Cell Cancer of the Lung

We report a 72-year-old male with past medical history of stage IV squamous lung cancer treated with radiation therapy and chemotherapy with gemcitabine/carboplatin. One year later, he presented with hemoptysis treated with another session of palliative radiotherapy. Two weeks later, patient developed aspiration pneumonia and further workup showed trachea-esophageal fistula documented by barium swallow. This case shows a rare complication of chemotherapy and radiation therapy on the setting of primary lung cancer.

Acquired TEF in Hodgkin Lymphoma in a Child: A Rare Clinical Association

BACKGROUND

Malignancy is the most common etiology of acquired fistulae between the tracheobronchial tree and esophagus. The majority are due to either primary bronchial or esophageal carcinoma, and are typically observed in adult population. The occurrence of tracheoesophageal fistula (TEF) in patients with Hodgkin lymphoma is a rare phenomenon.

OBSERVATION

We report a rare case of Hodgkin lymphoma with TEF in a 10-year-old girl at presentation. She also developed pulmonary tuberculosis later during the follow up. She was fed through a nasogastric tube to avoid aspiration through the fistulous tract. She did well with chemotherapy and anti-tubercular therapy.

CONCLUSIONS

Our case suggests TEF in Hodgkin lymphoma at the time of diagnosis is a rare complication in pediatric age group. Lymphoma-related TEF require far less active intervention, as against esophageal or bronchial malignancy related TEF.

Role of Bronchoscopy in Prompt Discharge From the Intensive Care Unit

BACKGROUND

Intensive care unit (ICU) stays are 2.5 times more costly than other hospital stays, and 93.3% of ICU use is for respiratory disease with ventilator support. The aim of this study was to assess the role of bronchoscopy on discontinuation of mechanical ventilation, and prompt discharge from ICU in our institution.

METHODS

Retrospective review of medical records of patients referred for bronchoscopic intervention for acute respiratory failure from malignant or benign central airway diseases requiring ICU admission.

RESULTS

Twelve critically ill patients were studied. Median (range) age was 63 years (range, 35 to 85 y). Nine (75%) had endotracheal tube, and 3 (25%) had tracheostomy tube. Nine (75%) of 12 patients admitted to ICU could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention. Median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002). Radiologically, all 8 patients with lung atelectasis on presentation experienced complete reexpansion of the lung on the day after bronchoscopic intervention.

CONCLUSION

The majority of patients in our cohort (75%) of benign and malignant etiology could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of mechanical ventilation and extubation after bronchoscopic intervention. We advocate early recognition and bronchoscopic intervention in suitable patients.

Concurrent chemoradiotherapy combined with enteral nutrition support: a radical treatment strategy for esophageal squamous cell carcinoma patients with malignant fistulae

Background

Concurrent chemoradiotherapy (CCRT) significantly increases the survival rate of esophageal squamous cell carcinoma (ESCC) patients with malignant fistulae. Recent clinical evidence has shown the benefits of enteral nutrition for malnourished cancer patients. In this study, we aimed to validate that, with the support of enteral nutrition, ESCC patients who develop malignant fistulae might be able to complete CCRT and achieve long-term survival.

Methods

We reviewed the medical records of 652 patients with ESCC who received definitive CCRT at Sun Yat-sen University Cancer Center between January 2010 and December 2012. Treatment outcome and toxicity were retrospectively evaluated in 40 ESCC patients with malignant fistulae. All the 40 patients were treated with CCRT and evaluated by clinical nutritionists using nutrition risk screening (NRS) before, during, and after treatment. Twenty-two patients received a nasogastric tube, and 18 underwent percutaneous endoscopic gastrostomy feeding. The median energy intake was 2166 kcal/day. Treatment response was evaluated at 3 months after the completion of CCRT.

Results

With a median follow-up of 18 months (range, 3–39 months), patients’ 1-year overall survival (OS) rate was 62.5%, and the estimated OS time was 25.5 months. Univariate analysis showed that the NRS score (P = 0.003), increase in NRS score (P = 0.024), fistula closure (P = 0.011), and response to treatment (P < 0.001) were significantly associated with OS. Multivariate analysis showed that tumor response (P = 0.044) and increase in NRS score (P = 0.044) were independent predictors of OS. Grade 3 vomiting was observed in 8 patients (20.0%), grade 3 neutropenia was observed in 11 patients (27.5%), and grade 3 cough was observed in 13 patients (32.5%); 2 patients (5.0%) died of massive bleeding during treatment.

Conclusions

CCRT combined with enteral nutrition support is effective for ESCC patients with malignant fistulae. Patients have an increased potential to be cured, especially those who experience complete response and have an increase in NRS score. Careful observation and nutrition support are required for patients with advanced T-category ESCC who undergo CCRT.

Double stenting for malignant oesophago-respiratory fistula

Introduction

The close anatomical relationship between the oesophagus and bronchial tree results in formation of an oesophago-respiratory fistula in a subset of patients with advanced oesophageal or lung cancer. In those patients stenting of both the oesophagus and tracheobronchial tree is a valid option of palliative treatment.

Aim

To determine the effectiveness, tolerance, quality of life, safety and survival after double stenting procedures.

Material and methods

Retrospective analysis of a prospectively collected database was performed, concerning consecutive patients with oesophago-respiratory fistulas treated with double stenting. In all patients the degree of dysphagia, respiratory function before and after the procedure, and quality of life were evaluated. Partially covered oesophageal self-expanding metallic stents (PCESEMS) were used for oesophageal stenting, and silicone Y-type or partially covered self-expanding bronchial and tracheal stents (PCASEMS) were used to restore airway patency.

Results

Between 2003 and 2015, 31 patients underwent double stenting due to oesophago-respiratory fistulas. Twenty-nine patients were diagnosed with oesophageal squamous cell carcinoma and 2 with bronchial carcinoma. In all patients, improvement in the general condition and quality of life was observed after airway patency restoration. Two patients required mechanical ventilation due to respiratory failure immediately after the procedure. Seven patients with oesophageal fistulas died because of bleeding in the long-term follow-up. Four patients required endoscopic re-intervention. Mean survival time was 67.1 days.

Conclusions

Double stenting is an effective procedure improving patients’ quality of life. However, life-threatening complications can occur.

Rare complication of bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia: a case report

Background

Mucormycosis is a rare and life-threatening invasive fungal infection. Pulmonary mucormycosis commonly occurs in patients with severe neutropenia. Typically, pulmonary mucormycosis causes tissue necrosis resulting from angioinvasion and subsequent thrombosis, so most cases can occur with necrotizing pneumonia and/or hemoptysis. Some complex cases may invade adjacent organs, such as the mediastinum, pericardium, and chest wall. However, to the best our knowledge there is little known regarding bronchoesophageal fistula due to pulmonary mucormycosis after induction chemotherapy for acute myeloid leukemia. We present a case report about this unusual presentation.

Case presentation

A 51-year-old Korean man was diagnosed as having acute myeloid leukemia and received induction chemotherapy. After prolonged severe neutropenia, he complained of coughing with aspiration. Imaging showed a bronchoesophageal fistula with extensive necrotizing pneumonia in the middle and lower lobes of his right lung. Bronchoscopy showed near total tissue necrosis in the middle lobe of his right lung, creating an orifice. A bronchial scope was passed through and was able to be connected with his esophagus; a bronchial wall biopsy was performed. Esophagoscopy revealed a large linear defect of his esophageal wall 30 cm from the incision that may have connected with the bronchus. A bronchial biopsy showed typical hyphae with necrotic tissue, indicating pulmonary mucormycosis. He was given amphotericin B, and a wide excision of lung and esophagus was planned. However, he suddenly died due to massive hemoptysis.

Conclusion

Here we present an extremely rare case of bronchoesophageal fistula with severe necrotizing pneumonia due to pulmonary mucormycosis.

Airway Covered Metallic Stent Based on Different Fistula Location and Size in Malignant Tracheoesophageal Fistula

BACKGROUND

Malignant tracheoesophageal fistula (MTEF) is a devastating complication of esophageal cancer, lung cancer or other carcinoma with a shorter life-span and poor life quality. The aim of this study was to assess the effect of airway stent insertion on MTEF patients.

METHODS

A total of 63 MTEF patients were included, 12 patients with lung cancer and 46 patients with esophageal cancers. Eight zones were proposed to classify various fistula locations. Airway stents were selected based on the various zones and fistula size.

RESULTS

Airway stents were successfully inserted in all patients, and both airway and esophageal stents in 8 patients. Most fistula were located in locations II (18/63, 28.6%), III (22/63, 34.9%), then VII (9/63, 14.3%). The stents included 10 (15.9%) I shaped, 8 (12.7%) L shaped and 45 (71.4%) Y shaped. Different stents were placed based on different locations and sizes of fistulas. Overall, mean survival time was 163 days (2-270 days). Most symptoms relieved after stent insertion. Mean Karnofsky score jumped from 43.0 ± 10.7 before stent placement to 66.7 ± 10.8 after stent insertion (P = 0.000). Complete closure was achieved in 45 patients (71.4%), and incomplete closure and leakage were found in 18 patients.

CONCLUSIONS

Airway stent insertion provides an effective approach to improve symptoms and quality of life. The choice of stent based on different fistula location and size may be a reasonable way in clinical practice.

The treatment strategy for tracheoesophageal fistula

With the development of endoscopic techniques, the treatment of tracheoesophageal fistula (TEF) has made marked progress. As surgical intervention is often not an advisable option due to advanced malignancy and poor performance status of the patients, bronchoscopic intervention provides a good choice to palliate symptoms and reconstruct the airway and esophagus. In this review, we focus on the application of interventional therapy of TEF, especially the application of airway stenting, and highlight some representative cases referred to our department for treatment.

Modified simultaneous integrated boost radiotherapy for an unresectable huge refractory pelvic tumor diagnosed as a rectal adenocarcinoma

A clinical trial of radiotherapy with modified simultaneous integrated boost (SIB) technique against huge tumors was conducted. A 58-year-old male patient who had a huge pelvic tumor diagnosed as a rectal adenocarcinoma due to familial adenomatous polyposis was enrolled in this trial. The total dose of 77 Gy (equivalent dose in 2 Gy/fraction) and 64.5 Gy was delivered to the center of the tumor and the surrounding area respectively, and approximately 20% dose escalation was achieved with the modified SIB technique. The tumor with an initial maximum size of 15 cm disappeared 120 d after the start of the radiotherapy. Performance status of the patient improved from 4 to 0. Radiotherapy with modified SIB may be effective for patients with a huge tumor in terms of tumor shrinkage/disappearance, improvement of QOL, and prolongation of survival.