Esophageal Stents in Aortoesophageal Fistulas-Anecdotal Experiences or New Armamentarium?

Clinical characteristics and risk factors for 30-day mortality in esophageal cancer patients with upper gastrointestinal bleeding: a multicenter study

Background

Esophageal cancer is a highly malignant neoplasm with poor prognosis. Of its patients, upper gastrointestinal bleeding (UGIB) is one of the most challenging and threatening conditions in the emergency department (ED). However, no previous studies have analyzed the etiologies and clinical outcomes in this specific population. This study aimed to identify the clinical characteristics and risk factors for 30-day mortality in esophageal cancer patients with UGIB.

Methods

This retrospective cohort study enrolled 249 adult patients with esophageal cancer presenting with UGIB in the ED. Patients was divided into the survivor and non-survivor groups, and their demographic information, medical history, comorbidities, laboratory parameters, and clinical findings were recorded. The factors associated with 30-day mortality were identified using Cox's proportional hazard model.

Results

Among the 249 patients in this study, 30-day mortality occurred in 47 patients (18.9%). The most common causes of UGIB were tumor ulcer (53.8%), followed by gastric/duodenal ulcer (14.5%), and arterial-esophageal fistula (AEF) (12.0%). Multivariate analyses indicated that underweight (HR = 2.02, p = 0.044), history of chronic kidney disease (HR = 6.39, p < 0.001), active bleeding (HR = 2.24, p = 0.039), AEF (HR = 2.23, p = 0.046), and metastatic lymph nodes (HR = 2.99, p = 0.021) were independent risk factors for 30-day mortality.

Conclusions

The most common cause of UGIB in esophageal cancer patients was tumor ulcer. AEF, accounting for 12% of UGIB in our study, is not an uncommon cause. Underweight, underlying chronic kidney disease, active bleeding, AEF, and tumor N stage > 0 were independent risk factors for 30-day mortality.

Aorto-esophageal fistula caused by fishbone ingestion: a case report on staged endovascular and endoscopic treatment

BACKGROUND

Aorto-esophageal fistula (AEF) caused by foreign bodies ingestion is a rare but devastating disorder. Thoracic endovascular aortic repair (TEVAR) has become a widely accepted intervention for treating aorto-esophageal fistulas. As for post-TEVAR esophageal defect, secondary esophagectomy has been the recommended choice for most of the AEFs, but there is no general consensus with regard to the need of secondary surgeries for patients in the absence of clear signs of reinfection or bleeding. We herein presented a case of an AEF caused by fishbone ingestion, after successful TEVAR, the esophageal lesion was closed endoscopically.

CASE PRESENTATION

A 38-year-old male presented with esophageal fistula for 4 months. He was diagnosed with AEF because of Chiari's triad after fishbone ingestion 4 months ago. Emergency thoracic aortic stent implantation was done, and given broad spectrum antibiotics and blood transfusion. His symptoms were improved, and discharged with an esophageal fistula left to heal itself. Nevertheless, after 4 months, re-examination of esophago-gastro-duodenoscopy revealed that the diameter of the fistula was changed from 3 to 6 mm. He was then admitted to our hospital for esophageal fistula repair. Laboratory examinations and chest computed tomography showed no signs of active infection, and endoscopic closure of the fistula was achieved with 4 clips. After that, he was discharged and gradually returned to normal diet.

CONCLUSION

For AEFs in the absence of active infection with repaired aorta but persistent esophageal fistula, endoscopic closure by endoclips might be an effective treatment choice.

Massive hemorrhage from an aortoesophageal fistula caused by esophageal stent implantation: A case report and literature review

RATIONALE

Aortoesophageal fistula (AEF) is the direct communication between the aorta and esophagus, which can cause fatal hemorrhage, and its incidence increased with the use of an esophageal stent (ES).

PATIENT CONCERNS

A 79-year-old man was admitted due to hemodynamic shock with massive hematemesis caused by AEF 1 month after the implantation of an ES.

DIAGNOSES

Computed tomography angiography visualized an AEF with an ulcer-like projection on the aortic arch where the ES was placed. Angiography of the aorta revealed extravasation of contrast media from the aortic arch into the stented esophagus, which confirmed the diagnosis.

INTERVENTIONS

Thoracic endovascular aortic repair (TEVAR) was performed for massive hematemesis caused by ES-related, AEF but did not solve the underlying problem, leading to the second fatal hemorrhage.

LESSONS

TEVAR for the unique treatment of ES-related AEF is feasible in certain cases but may lead to collapse after a specific period.