Aorto-oesophageal fistula: a complication of oesophageal stenting

Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video)

BACKGROUND AND AIMS

The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates.

METHODS

Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract.

RESULTS

Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself.

CONCLUSIONS

EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Aortic fistula after neoadjuvant chemoradiotherapy and esophagectomy for esophageal carcinoma: an unusual cause of sudden death

Aortic fistula to the enteric tract is an uncommon but recognized complication of esophagectomy, whereas an aortorespiratory fistula is usually described in the setting of aortic disease or previous aortic surgery. We describe 2 cases of fatal aortic fistula occurring after esophagectomy and neoadjuvant chemoradiotherapy, both encountered at autopsy.The first case is an aortobronchial fistula occurring in a 47-year-old male in the early postoperative setting. Death was caused by rupture of the fistula into the posterior mediastinum with transhiatal extension and hemoperitoneum. The tissue adjacent to the fistula showed radiation effect, and an esophageal stent had been placed before surgery. The second case is an aortogastric tube fistula occurring in a 50-year-old male 2 years after surgery and resulting in fatal gastrointestinal hemorrhage. The fistula involved the site of anastomosis and a surgical clip was present in the adjacent soft tissue.The development of aortic fistula after esophagectomy for esophageal carcinoma is rare, but should be considered at autopsy as a potential cause of unexpected, sudden death in these patients. Possible inciting mechanisms in this setting include the presence of foreign material (stent placement and surgical clips) and previous chemoradiation.

Esophageal perforation caused by a fish bone treated with surgically indwelling drainage and fibrin glue injection for fistula formation

We herein report a case of thoracic esophageal perforation caused by a fish bone. The patient was a 68-year-old female who presented with a persistent sore throat after eating sea bream four days previously. She was diagnosed with an esophageal perforation and posterior mediastinal abscess formation by chest computed tomography and inflammatory findings in her blood test. Surgically indwelling drainage was able to effectively control the leakage of contaminants and infection. Endoscopic injection of fibrin glue into the long-standing thoracic-esophageal fistula promoted closure of the esophageal wall defect and enabled her to restart oral intake. This case report suggests that effective drainage and the use of fibrin glue sealant may be one of the treatment options for esophageal perforation.

Short-term esophageal stenting in the management of benign perforations

OBJECTIVES

The standard approach to benign esophageal perforations consists of conservative treatment or surgery. In this study, we investigated the efficacy of short-term stent placement for nonmalignant esophageal perforations.

METHODS

This is a prospective single-center study of patients with benign esophageal perforations in whom a removable self-expandable stent was placed. Data were collected from a prospective database, endoscopy records, and operation reports. To obtain follow-up data, we contacted the patients, their relatives, or their general practitioner.

RESULTS

A total of 33 patients underwent stent insertion owing to an iatrogenic perforation (n=19), Boerhaave's syndrome (n=10), or other causes (n=4); this resulted in an immediate and complete sealing of the lesion in 32 patients (97%). Stents migrated in 11 patients (33%). Four patients required an esophageal resection for failed stent therapy (n=3) and failed stent removal (n=1). The 90-day mortality rate was 15%. A total of 33 endoscopic stent extractions were attempted. Overall, 23 stents were extracted within 6 weeks (group I) and 10 stents between 6 and 84 weeks (group II). Extractions were uncomplicated in all patients in group I (100%) vs. in 5 patients in group II (50%) (P=0.001). Six extraction-related complications occurred in group II, including two self-limiting bleedings, three stent fractures, and one impacted stent.

CONCLUSIONS

In patients with a benign esophageal perforation, temporary stent therapy is effective and provides a good alternative to surgery. Complications due to stent removal can be prevented by removal of the prosthesis within 6 weeks after insertion, without compromising the efficacy of treatment.

An aortoesophageal fistula in patient with lung cancer after chemo-irradiation and subsequent esophageal stent implantation

An aortoesophageal fistula (AEF) is uncommon but is frequently fatal. Most cases are attributable to a thoracic aortic aneurysm. Other common causes include malignant intrathoracic neoplasm, foreign body ingestion, endovascular stent graft repair for thoracic aortic disease, and esophageal surgery. We report a case of an AEF that developed after chemo-irradiation and subsequent esophageal stent implantation in patient with non-small cell lung cancer. The patient underwent self expanding metallic esophageal stent implantation for an esophageal stricture after chemotherapy and radiotherapy. However, 1 month later, he presented with hematemesis. Chest computed tomography and aortography revealed a fistula from the descending thoracic aorta to the stented esophagus. The patient expired 36 hours after initial hematemesis. To our knowledge, this is the first confirmed report of an AEF in patient with a nonesophageal malignancy that had undergone chemo-irradiation and subsequent esophageal stent implantation. We recommend that special caution be exercised when performing esophageal stent implantation in patients who have received prior radiotherapy to the thorax including the esophagus.

Diagnosis and management of primary aortoenteric fistulas--experience learned from eighteen patients

OBJECTIVE

Misdiagnosis of primary aortoenteric fistula (PAEF) frequently occurs in clinical practice owing to the rarity of this condition. Herein we present the experience of diagnosis and management for PAEF.

METHODS

Eighteen patients with PAEF at 2 medical centers in China were reviewed. The clinical data, diagnostic procedures, treatment options, and patient outcomes were evaluated.

RESULTS

The fistulas were located at esophagus (5), duodenum (8), jejunum (3), ileum (1), and transverse colon (1). The etiologies include atherosclerotic aneurysms and foreign body. Typical abdominal triad (pain, upper GI bleeding, and abdominal pulsating mass) was found in 27.8% of patients, and Chiari's triad (mid-thoracic pain, sentinel hemorrhage, and massive bleeding after a symptom-free interval) was present in 3 of 5 cases with thoracic aortoesophageal fistulas. All patients had an average of 3.6 (1-9) episodes of gastrointestinal bleeding. The interval between the first sentinel hemorrhage and ultimate exsanguination ranged from 5 hours to 5 months (median, 4 days). Six patients (33.3%) were diagnosed or suggested by diagnostic tools including endoscopy, computerized tomography, and arteriography. Others were diagnosed by surgical exploration (7) and autopsy (5). One to 5 rounds (mean 1.8) of misdiagnosis occurred in 15 patients. Six patients recovered from surgery and remained well during a 36-month follow-up. The surgical options used included in situ replacement with vascular graft (3), aneurysmorraphy and closure of fistula (1), and endovascular stenting (2).

CONCLUSIONS

A high index of suspicion is necessary for correct diagnosis and prompt management of PAEF, especially in patients with aortoiliac aneurysms presenting with gastrointestinal bleeding. In situ graft replacement and endovascular stent-graft may be the preferred therapeutic options.

Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents

BACKGROUND

Spontaneous or iatrogenic esophageal perforations after endoscopic procedures are potentially life-threatening events with a considerable mortality rate. The aim of this study was to demonstrate that a nonoperative endoscopic treatment with self-expanding metal stents may have a lower morbidity and mortality rate compared with surgical treatment.

METHODS

A nonrandomized observational study was conducted with 15 consecutive patients between January 1997 and June 2004. Benign spontaneous and iatrogenic esophageal perforations after endoscopic procedures were treated with self-expandable metal stents.

RESULTS

Seven patients (group 1) underwent stent insertion with an average time delay of 45 minutes. In 8 patients (group 2), the median delay was 123 hours. All patients in group 1 had an uneventful recovery and left hospital 5 days (range, 3 to 9) after stent insertion. One patient in group 2 (1 of 8) died of pneumonia after 6 days. In any other cases, perforations healed successfully after stent placement, but the clinical course was generally complicated with sepsis and multiple organ failure. The average hospital stay was 44 days (range, 15 to 70).

CONCLUSIONS

Immediate insertion of a self-expandable metal stent enables an excellent outcome with minimal mortality and morbidity without the need for operation. Even in cases of old esophageal perforations, sealing with self-expandable metal stents is still a good option although the clinical course is much less impressive than in early treated perforations.

Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients

PURPOSE

To evaluate long-term clinical results of palliative treatment of esophagorespiratory fistulas (ERFs) with covered expandable metallic stents.

MATERIALS AND METHODS

Sixty patients with ERFs due to esophageal or bronchogenic carcinoma and one patient with ERF due to pressure necrosis caused by initial esophageal stent placement for esophageal carcinoma were treated with covered expandable esophageal or tracheobronchial metallic stents. Information about technical success of stent placement, initial clinical success and failure, fistula reopening, and complications was obtained. Survival curves for both patient groups with initial clinical success and failure were obtained and compared with Kaplan-Meier methods and log-rank test.

RESULTS

Stent placement was technically successful in all patients, with no immediate procedural complications. The stent completely sealed off the fistula in 49 (80%) of 61 patients so that they had no further aspiration symptoms (initial clinical success). Twelve (20%) of 61 patients had persistent aspiration symptoms due to incomplete ERF closure (initial clinical failure). During follow-up, the fistula reopened in 17 (35%) of 49 patients with initial clinical success: In eight patients, the reopened ERF was sealed off successfully with stent placement or balloon dilation. In two patients with reopened ERF caused by food impaction, the reopened fistula resolved spontaneously. Seven patients did not undergo further treatment. All patients died during follow-up, and mean survival was 13.4 weeks (range, 1-56 weeks) after stent placement. Mean survival in patients with initial clinical success was significantly longer than that in patients with initial clinical failure (15.1 vs 6.2 weeks, P <.05).

CONCLUSION

Covered expandable metallic stents were placed in 61 patients with ERFs, but the initial clinical success rate was poor and the rate of reopening was high; however, interventional treatment was effective for sealing off reopened ERFs.

[Esophageal disease: is cross sectional imaging contributive?]

For a long time, esophagography and endoscopy were the major diagnostic tests used for evaluation of the esophagus. Now, the development of computed tomography, endosonography and MR imaging has permitted more comprehensive evaluation of esophageal diseases. Cross sectional imaging is essential to evaluate the relationship between esophageal lesions and adjacent mediastinal structures and to evaluate the thickness of the esophageal wall.

Palliation of malignant dysphagia with expanding metallic stents

PURPOSE

The authors describe their experience with expanding metallic stents for the palliation of malignant dysphagia.

MATERIALS AND METHODS

During a 52-month period, 138 stents were inserted in 121 patients with malignant esophageal obstruction. The average age was 74 years; there were 78 men and 43 women. Data regarding the degree of initial dysphagia, presence of an esophago-respiratory fistula, effect of stent placement on swallowing ability, complications at the time of stent placement, and long-term survival were obtained.

RESULTS

An improvement in dysphagia symptoms was recorded in more than 95% of patients. The average survival after stent placement was 24 weeks. Complications necessitating further intervention occurred in 26 patients.

CONCLUSION

Insertion of self-expanding metallic endoprostheses for the palliation of malignant esophageal obstruction is an effective therapy that can be carried out with relative ease. Successful palliation of symptoms can be expected in more than 95% of cases.