Management of oesophageal fistula by radiologically-guided instillation of tissue adhesive

Systematic review of cyanoacrylate embolization for refractory gastrointestinal fistulae: a promising therapy

BACKGROUND

Surgical management of gastrointestinal fistulae has been reported to carry a 30-day morbidity rate up to 82% and a mortality rate ranging from 2% to 4.8%; thus nonoperative alternatives are required. The aim of the present study was to assess the current experience on the use of cyanoacrylates in the management of these fistulae.

METHODS

A systematic review was carried out on Medline, Embase, The Cochrane database, Academic Search Complete, MedicLatina, and SciELO for English, Spanish, and Portuguese articles dealing with refractory fistulae by means of cyanoacrylate embolization therapy. Publication dates were restricted from 1969 to present. Outcome parameters were study design, number of participants, etiology of the fistula, approach, material used, success rate, complications, and mortality.

RESULTS

Electronic search yielded a total of 377 articles. After a meticulous screening, only 14 studies dealing with foregut/midgut fistulae and 6 addressing hindgut fistulae were included. All the included articles were prospective and retrospective case series. Cumulative success rate was 81% (range 0% to 100%) and 3 out of 203 patients (1%) developed minor complications.

CONCLUSION

Cyanoacrylate embolization of nearly all types of refractory gastrointestinal fistulae is a feasible and harmless technique. Prospective controlled studies are required to support the available evidence.

Closure of tracheoesophageal fistulas with chemotherapy and radiotherapy

In patients who have esophageal cancer with a tracheoesophageal fistula, chemotherapy and radiotherapy are usually contraindicated because it is thought to enlarge the fistula. The records of 50 patients who had esophageal cancer and received simultaneous chemotherapy and radiotherapy from January 1992 to January 1997 were evaluated in the Medical Oncology Section of the Veterans Administration Medical Center, Washington, D.C. All patients were staged radiographically and endoscopically. Four patients developed a tracheoesophageal fistula while receiving treatment. One patient developed a fistula before treatment and another patient developed a fistula after treatment. Closure of the tracheoesophageal fistulas was achieved in 4 of 5 patients who responded to therapy and in those who developed fistulas before or during therapy. One of the patients whose fistula did not close died during therapy, whereas the other who developed a fistula after therapy underwent stenting. This finding indicates that development of a tracheoesophageal fistula is not a contraindication to chemotherapy and radiotherapy, and patients who are responsive to therapy may have closure of their fistulas.