Tracheoesophageal fistula closed by a new gastrointestinal occluder device

Airway and anesthesia management in tracheoesophageal fistula closure implantation: a single-centre retrospective study

OBJECTIVE

To review and analyze the airway and anesthesia management methods for patients who underwent endoscopic closure of tracheoesophageal fistula (TEF) and to summarize the experience of intraoperative airway management.

METHOD

We searched the anesthesia information system of the First Affiliated Hospital of Nanjing Medical University for anesthesia cases of TEF from July 2020 to July 2023 and obtained a total of 34 anesthesia records for endoscopic TEF occlusion. The intraoperative airway management methods and vital signs were recorded, and the patients' disease course and follow-up records were analyzed and summarized.

RESULTS

The airway management strategies used for TEF occlusion patients included nasal catheter oxygen (NCO, n = 5), high-flow nasal cannula oxygen therapy (HFNC, n = 4) and tracheal intubation (TI, n = 25). The patients who underwent tracheal intubation with an inner diameter of 5.5 mm had stable hemodynamics and oxygenation status during surgery, while intravenous anesthesia without intubation could not effectively inhibit the stress response caused by occluder implantation, which could easily cause hemodynamic fluctuations, hypoxemia, and carbon dioxide accumulation. Compared with those in the TI group, the NCO group and the HFNC group had significantly longer surgical times, and the satisfaction score of the endoscopists was significantly lower. In addition, two patients in the NCO group experienced postoperative hypoxemia.

CONCLUSION

During the anesthesia process for TEF occlusions, a tracheal catheter with an inner diameter of 5.5 mm can provide a safe and effective airway management method.

Covered SEMS failed to cure airway fistula closed by an amplatzer device

BACKGROUND

Airway fistula is a rare but threatening complication associated with high rates of morbidity and mortality. We report the experience of Amplatzer device application in airway fistulae that failed to be cured with a covered self-expandable metallic stent (SEMS).

MATERIALS AND METHODS

Patients who failed occlusion with a covered self-expandable metallic stent and received Amplatzer device placement from Jan 2015 to Jan 2020 were retrospectively enrolled. A total of 14 patients aged 42 to 66 years (55.14 ± 7.87) were enrolled in this study. The primary diseases, types of fistula, types of stents, duration, size of fistula, and follow-up were recorded.

RESULTS

All 14 patients with airway fistula failed to be occluded with a covered metallic stent and received Amplatzer device placement. Among the 14 patients, 6 had BPF, 3 had TEF and 5 had GBF. The average stent time was 141.93 ± 65.83 days. The sizes of the fistulae ranged from 3 to 6 mm. After Amplatzer device placement, the KPS score improved from 62.14 ± 4.26 to 75.71 ± 5.13 (P < 0.05). No procedure-related complications occurred. During the 1-month, 3-month and 6-month follow-ups, all the Amplatzer devices were partially surrounded with granulation. Only 1 patient with BPF failed with Amplatzer device occlusion due to the recurrence of lung cancer.

CONCLUSION

In conclusion, the application of the Amplatzer device is a safe and effective option in the treatment of airway fistula that failed to be occluded with SEMSs.

First-time use of a porcine small intestine submucosal plug device to close an acquired tracheo-esophageal fistula

BACKGROUND

Acquired tracheo-esophageal fistula (TEF) is a rare, life-threatening pathology, responsible for severe comorbidities. Its management is a real therapeutic challenge and remains controversial.

CASE PRESENTATION

We report the first case of endoscopic treatment of TEF by using a porcine small intestine submucosal (SIS) plug device in a young quadriplegic patient after failed surgical closure by cervicotomy. After 1 year of follow-up, oral feeding of the patient was resumed and no clinical signs of fistula recurrence were evident.

CONCLUSION

To our knowledge, we obtained for the first time, a satisfactory result for TEF closure with the use of a porcine SIS plug.

Endoscopic closure of refractory upper GI-tracheobronchial fistulas with a novel occluder: a prospective, single-arm, single-center study (with video)

BACKGROUND AND AIMS

Upper GI-tracheobronchial fistula is a morbid condition with high mortality. It is a challenge for endoscopists because currently available treatments have severe limitations. In this study we assessed the efficacy and safety of an occluder we invented for endoscopic closure of refractory upper GI-tracheobronchial fistulas.

METHODS

This was a prospective, single-arm, single-center trial conducted between September 2020 and March 2022. All patients undergoing occluder placement were eligible to enroll. The primary endpoints were clinical success rate (CSR) and complete closure rate (CCR) at 3 months and safety. Secondary efficacy endpoints were technical success rates, CSRs and CCRs at 1 and 6 months, near-complete closure rates, change from baseline in body mass index (BMI), and health-related quality of life (HRQoL) at 1, 3, and 6 months.

RESULTS

Twenty-eight patients (mean age, 63.2 years; 23 men) were enrolled. Eighteen through-the-scope occluders (TTSOs) and 10 through-the-overtube occluders (TTOOs) were implanted, with a technical success rate of 100%. The mean procedure time for the TTSO and TTOO groups were 28.0 ± 8.0 minutes and 31.8 ± 7.7 minutes, respectively. The CSRs at 1, 3, and 6 months were 92.9%, 96.4%, and 92.0% and the CCRs were 60.7%, 60.7%, and 60.0%, respectively. The mean BMI at 3 and 6 months and HRQoL at 1, 3, and 6 months were significantly increased compared with baseline (P < .05). Two completely occluded fistulas had 1-sided or complete healing by coverage of granulation tissue and re-epithelialized mucosa at a follow-up of 6 and 12 months. All 14 adverse events were either mild and transient or easily corrected.

CONCLUSIONS

Our clinical outcomes suggest that this novel GI occluder is a safe and effective salvage option for patients with refractory upper GI-tracheobronchial fistulas. (Clinical trial registration number: ChiCTR2000038566.).

Anesthesia management for tracheoesophageal fistula closed with a new gastrointestinal occluder device: a case report

Background

Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. A new gastrointestinal occluder device provides treatment for TEF patients. However, TEF-related pneumonia and respiratory failure increase the difficulty of anesthesia management, especially in airway management.

Case presentation

A 64-year-old man with thoracic esophageal cancer underwent esophagectomy and gastric tube reconstruction one year ago. The patient presented with recurrent cough and sputum after surgery. Gastroscopy revealed a fistula between the esophagogastric anastomotic site and membrane of the trachea. Therefore, the patient received implantation of a new gastrointestinal occluder device under gastroscopy combined with tracheoscopy. Airway management under general anesthesia was discussed with an interdisciplinary decision, and cuffed endotracheal tube with an inner diameter of 5.5 mm was chosen. This airway management ensured adequate oxygenation during the operation and provided sufficient space for the operation of the tracheoscope in the trachea. Finally, the TEF disappeared after the operation, and the patient was administered an oral diet on the first postoperative day.

Conclusions

The implantation of a new gastrointestinal occluder device under gastroscopy combined with tracheoscopy provides a new treatment for TEF patients. This case report suggests that it is important to select an endotracheal tube with an appropriate inner diameter that can not only meet the requirements of ventilation but also does not affect the operation of tracheoscopy in the trachea.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-02038-8.

The efficacy and long-term outcomes of endoscopic full-thickness suturing for chronic gastrointestinal fistulas with an Overstitch device: is it a durable closure?

BACKGROUND AND AIM

Endoscopic closure of chronic gastrointestinal fistulas (CGFs) is challenging due to their epithelialized surfaces. The aim of this study was to assess the efficacy and long-term closure rate of endosuturing for CGFs with an Apollo Overstitch device.

PATIENTS AND METHODS

Consecutive CGF patients undergoing endosuturing for fistula closure from April 2018 to January 2020 at the First Affiliated Hospital of Nanjing Medical University were enrolled for retrospective review. Demographics, fistula characteristics, details of the suturing procedures and outcomes were collected for analysis.

RESULTS

Twenty patients (mean age 59.8 ± 9.1 years; 85% males) with a total of 23 CGFs underwent sutured fistula closure. Esophagotracheal fistulas were the most common CGFs (12/23, 52.2%), and prior cancer surgery was the most common fistulization etiology (14/20, 70%). Twelve patients (12/20, 60%) had undergone failed endoscopic attempts at fistula closure before suturing. Additional endoscopic therapies used during suturing were 100% argon plasma coagulation, 50% clip fixation, and 10% stent placement. Although all patients undergoing suturing achieved immediate technical success of fistula closure, sustained fistula closure was observed in only 5 patients (5/20, 25.0%) on surveillance endoscopy 3 months after suturing with a mean follow-up of 19.5 months. Esophagotracheal fistula patients were predisposed to shorter dehiscence-free survival than those with other fistulas (HR 3.378; 95% CI 1.127-10.13).

CONCLUSIONS

Endosuturing is safe and should be considered for use as the first-line or salvage therapy for CGF closure, primarily for patients with fistulas not involving the trachea. However, the long-term healing of CGFs by suturing is challenging, and CGF patients might not benefit from repeated suturing.

Amplatzer occluders for refractory esophago-respiratory fistulas: a case series

Background and study aims  Endoscopic management of esophagorespiratory fistulas (ERF) is challenging and currently available options (stents, double pigtail, endoscopic vacuum therapy) are not very effective. We report the feasibility and efficacy of endoscopic placement of Amplatzer cardiovascular occluders for this indication. Patients and methods  This was a single-center, prospective study (June 2019 to September 2020) of all patients with non-malignant ERF persistent after conventional management with esophageal and/or tracheal stents. The primary outcome was the technical feasibility of Amplatzer placement. Secondary outcomes were clinical success defined by effective ERF occlusion and resolution of respiratory symptoms allowing oral food intake. Results  Endoscopic placement of Amplatzer occluders was feasible in 83 % of patients (5/6), with a 50 % (3/6) clinical success rate at 9 months. The mortality rate was 33 % (2/6). Conclusions  An Amplatzer cardiac or vascular occluder is a feasible and safe treatment option for refractory ERF, with a 50 % short-term clinical success.