Radiologic localization of esophageal level: comparison with distance from incisor at endoscopy

Stent-associated esophagorespiratory fistulas: incidence and risk factors

BACKGROUND

Esophageal self-expandable stents (SESs) effectively treat strictures and leaks but may be complicated by a stent-associated esophagorespiratory fistula (SERF). Little is known about SERFs.

OBJECTIVE

To determine the incidence, morbidity, mortality, and risk factors for SERF.

DESIGN

Retrospective case-control study.

SETTING

Single referral center.

PATIENTS

All adults undergoing esophageal SES placement during a 10-year period.

INTERVENTION

Stent placement.

MAIN OUTCOME MEASUREMENTS

Occurrence of SERF, morbidity, and mortality.

RESULTS

A total of 16 of 397 (4.0%) patients developed SERF at a median of 5 months after stent placement (range 0.4-53 months) including 6 of 94 (6%), 10 of 71 (14%), and 0 of 232 (0%) of those with lesions in the proximal, middle, and distal esophagus, respectively (overall P < .001). SERF occurred in 10% of those with proximal and mid-esophageal lesions, including 14% with benign strictures, 9% with malignant strictures, and none with other indications for SES placement (P = .27). The risk was highest (18%) in patients with benign anastomotic strictures. Risk factors for development of SERF included a higher Charlson comorbidity index score (odds ratio [OR] 1.47 for every 1-point increase; P = .04) and history of radiation therapy (OR 9.41; P = .03). Morbidity associated with SERF included need for lifelong feeding tubes in 11 of 22 (50%) and/or tracheostomy or mechanical ventilation in 5 of 22 (23%). Median survival after diagnosis was 4.5 months (range 0.35-67), and 7 patients survived less than 30 days.

LIMITATIONS

Retrospective design, limited statistical power.

CONCLUSION

SERF is a morbid complication of SES placement for strictures of the proximal and mid-esophagus. The dominant risk factors for development of SERF are prior radiation therapy and comorbidity score.

The transnasal esophagoscopy documentation dilemma

OBJECTIVE

To determine radiographically the anatomic length difference between the nasal and oral aerodigestive tracts and to clarify gaps in the literature regarding standardized landmark measurements and documentation techniques in transnasal esophagoscopy, as opposed to traditional transoral esophagoscopy.

STUDY DESIGN

This is a prospective radiographic cohort study.

METHODS

Digital computerized tomography measurement techniques were used to determine the difference in length between the nasal and oral aerodigestive tracts. Using sagittal plane images from consecutive patients, the mean nares-cricoid (NC) distance, upper incisor-cricoid (IC) distance, and their mean differences were determined. Male, female, and overall distances and differences were calculated. Standard deviations, 95% confidence intervals, and 90% prediction intervals were also calculated. Mean difference data were applied to reported standard oral esophagoscopy landmark measurements to convert to standard landmark measurements from the nares.

RESULTS

Overall mean NC and IC distances were 175.4 mm and 147.5 mm, respectively. For males, these mean distances were 185.5 mm and 155.0 mm, respectively. For females, these mean distances were 165.3 mm and 140.0 mm, respectively. Overall mean NC to IC difference was 27.9 mm. The mean NC to IC difference for males and females was 30.5 mm and 25.2 mm, respectively.

CONCLUSIONS

Historically, landmark and report measurements in esophagoscopy have been measured and standardized from the upper incisor. This study demonstrates and clarifies the inherent anatomic length difference of the nasal and oral aerodigestive tracts and the resultant documentation dilemma produced by transnasal esophagoscopy techniques. These data provide easy conversion of esophagoscopy measurements reported from the incisors or nares, providing better communication between endoscopists of different disciplines and techniques.

Variability of the Carina–Incisor Distance as assessed by Endoscopic Ultrasound

AIM

The purpose of this study is to demonstrate variability of the carina-incisor distance (CID), and define morphological factors associated with this.

MATERIALS AND METHODS

The carina is clearly visualised on endoscopic ultrasound (EUS), and the CID was measured in 50 patients (29 men, 21 women) undergoing EUS for various indications (30 oesophageal cancer, 20 other) with Olympus UM-20 (used in 24 cases) or MH-908 (used in 26 cases) radial echoendoscopes. Patient height and weight were compared with CID using Pearson's correlation coefficient.

RESULTS

Mean CID was 25.7 cm, with a range of 20.5-29 cm (SD +/- 1.99). There was no difference between the measured CID in the oesophageal cancer and non-oesophageal cancer groups, or between the two types of echoendoscope. There was highly significant positive correlation between patient height and CID (r = +0.750; P < or = 0.01).

CONCLUSION

This study demonstrates considerable variability of the CID from 20.5-29 cm. It is no longer appropriate to assume a 'normal' carinal level of 25 cm in all patients. In this study, if the carina was accepted to lie at 25 cm, this would have led to radiation therapy missing macroscopic disease, a so called 'geographic miss', in nine of the 50 (18%) patients. We now routinely record the level of the CID, the upper and lower extent of the primary tumour and lymph-node metastases with reference to the incisor teeth. This is simple to perform and may assist in radiotherapy planning by reducing the geographic miss rate.