Silicone Pectoral Implant to Solve Aesthetic Chest Deformity After Pectoralis Flap Harvesting for Laryngotracheal Reconstruction

BACKGROUND

 The pectoralis major musculocutaneous flap has been considered for decades the workhorse in head and neck reconstruction. However, the disadvantages of the pectoralis flap include the morbidity of the donor site in terms of cosmetic and functional results. A silicone pectoral implant  can be used to solve such aesthetic chest deformity in male patients.

METHODS

A 33-years-old man with a history of cervical tracheoesophageal fistula after a blunt trauma due to a motorcycle accident, previously reconstructed with a pectoralis major flap, consulted our Plastic Surgery Department for an aesthetic defect of the donor site . The use of an anatomical pectoral implant was planned with the aim of aesthetic reshaping of the male chest. A pocket was created following the preoperative design to position a 190 cc pectoral implant. Dissection was performed in a subcutaneous plane that included the underneath adipose tissue layer and then over the pectoralis minor and the serratus muscle. Three months later, in a second stage, lipofilling of the depressed areas was performed with 100 ml of adipose tissue obtained from the abdomen.

RESULTS

After two years of follow-up, the patient obtained a satisfactory aesthetic result, with an improvement in the projection of the thorax and the symmetry of the body contour. As the implant was placed into the subcutaneous pocket, no functional compromise in shoulder flexion or adduction was detected during follow-up.

CONCLUSIONS

 The pectoral implant technique seems safe and provides reshaping of the male chest wall, significantly improving the cosmetic appearance of the patient. In addition, its use with associated procedures such as lipofilling allows optimal results to be obtained. To the best of our knowledge, this is the first case to describe the use of a pectoral implant to solve donor site morbidity after pectoralis flap harvesting for any reconstructive purpose. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Optimization of tracheoesophageal fistula model established with T-shaped magnet system based on magnetic compression technique

BACKGROUND

The magnetic compression technique has been used to establish an animal model of tracheoesophageal fistula (TEF), but the commonly shaped magnets present limitations of poor homogeneity of TEF and poor model control. We designed a T-shaped magnet system to overcome these problems and verified its effectiveness via animal experiments.

AIM

To investigate the effectiveness of a T-shaped magnet system for establishing a TEF model in beagle dogs.

METHODS

Twelve beagles were randomly assigned to groups in which magnets of the T-shaped scheme (study group, n = 6) or normal magnets (control group, n = 6) were implanted into the trachea and esophagus separately under gastroscopy. Operation time, operation success rate, and accidental injury were recorded. After operation, the presence and timing of cough and the time of magnet shedding were observed. Dogs in the control group were euthanized after X-ray and gastroscopy to confirm establishment of TEFs after coughing, and gross specimens of TEFs were obtained. Dogs in the study group were euthanized after X-ray and gastroscopy 2 wk after surgery, and gross specimens were obtained. Fistula size was measured in all animals, and then harvested fistula specimens were examined by hematoxylin and eosin (HE) and Masson trichrome staining.

RESULTS

The operation success rate was 100% for both groups. Operation time did not differ between the study group (5.25 min ± 1.29 min) and the control group (4.75 min ± 1.70 min; P = 0.331). No bleeding, perforation, or unplanned magnet attraction occurred in any animal during the operation. In the early postoperative period, all dogs ate freely and were generally in good condition. Dogs in the control group had severe cough after drinking water at 6-9 d after surgery. X-ray indicated that the magnets had entered the stomach, and gastroscopy showed TEF formation. Gross specimens of TEFs from the control group showed the formation of fistulas with a diameter of 4.94 mm ± 1.29 mm (range, 3.52-6.56 mm). HE and Masson trichrome staining showed scar tissue formation and hierarchical structural disorder at the fistulas. Dogs in the study group did not exhibit obvious coughing after surgery. X-ray examination 2 wk after surgery indicated fixed magnet positioning, and gastroscopy showed no change in magnet positioning. The magnets were removed using a snare under endoscopy, and TEF was observed. Gross specimens showed well-formed fistulas with a diameter of 6.11 mm ± 0.16 mm (range, 5.92-6.36 mm), which exceeded that in the control group (P < 0.001). Scar formation was observed on the internal surface of fistulas by HE and Masson trichrome staining, and the structure was more regular than that in the control group.

CONCLUSION

Use of the modified T-shaped magnet scheme is safe and feasible for establishing TEF and can achieve a more stable and uniform fistula size compared with ordinary magnets. Most importantly, this model offers better controllability, which improves the flexibility of follow-up studies.

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.

Perforator-based chimeric ulnar forearm microvascular free tissue transfer reconstruction of post-radiated tracheoesophageal puncture fistulae

Tracheoesophageal puncture (TEP) performed during total laryngectomy in the primary treatment of laryngeal cancer is the standard method for voice restoration. Following adjuvant radiotherapy, the TEP site can experience complications resulting in a tracheoesophageal fistula (TEF) with chronic leakage making oral alimentation unsafe due to aspiration. Here, we describe a technique using chimeric ulnar artery perforator forearm free flaps (UAPFF) in the reconstruction of these complex deformities. Four patients underwent chimeric UAPFF reconstruction of TEP site TEFs following primary TL with TEP and adjuvant radiotherapy. No flap failures or surgical complications occurred. Average time from end of radiotherapy to persistent TEF was 66 months (range 4-190 months). All patients had resolution in their TEF with average time to total oral diet achievement of 22 days (14-42 days). Chimeric UAPFF reconstruction is a safe and effective method to reconstruct recalcitrant TEP site TEFs.

Case report of radiotherapy combined with anlotinib and immunotherapy for a patient with esophageal cancer and esophageal fistula

BACKGROUND

Esophageal cancer (EC) is a frequent gastrointestinal malignancy. The most common types of EC pathology worldwide are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC). Although surgical resection is still the main treatment modality for EC, most patients are already lost to surgery at the time of presentation due to the late stage. In recent years, the development of radiation therapy (RT) combined with targeted therapy (TT) and immunization therapy (IT) has brought more options for the treatment of EC. During radiation therapy, the radiation therapy area is very close to the trachea and esophagus, so radiation therapy may cause damage to the tissues of the trachea and esophagus, which is also known as a tracheoesophageal fistula (TF). We present the case of an EC patient who developed TF during radiation therapy and gradually improved after a combination of anlotinib and immunotherapy.

METHODS

The patient was diagnosed with poorly differentiated ESCC by pathological biopsy and treated with "lobaplatin + Tegafur Gimeracil Oteracil Porassium Capsule" for 5 cycles.

RESULTS

CT scan of the chest showed progression after treatment. During RT, the patient developed radiotherapy-related adverse effects, which were relieved by symptomatic support therapy. At the end of RT, the patient developed TF, but we chose to let the patient continue his radiation treatment plan with the anti-angiogenic drug "anlotinib."

CONCLUSION

After radiation therapy, the patient continued to be treated with anlotinib and immunotherapy with camrelizumab, and the patient's lesion improved.

Surgical strategies for benign acquired tracheoesophageal fistula

OBJECTIVES

Tracheoesophageal fistula (TEF) is characterized by abnormal connectivity between the posterior wall of the trachea or bronchus and the adjacent anterior wall of the oesophagus. Benign TEF can result in serious complications; however, there is currently no uniform standard to determine the appropriate surgical approach for repairing TEF.

METHODS

The PubMed database was used to search English literature associated with TEF from 1975 to October 2023. We employed Boolean operators and relevant keywords: 'tracheoesophageal fistula', 'tracheal resection', 'fistula suture', 'fistula repair', 'fistula closure', 'flap', 'patch', 'bioabsorbable material', 'bioprosthetic material', 'acellular dermal matrix', 'AlloDerm', 'double patch', 'oesophageal exclusion', 'oesophageal diversion' to search literature. The evidence level of the literature was assessed based on the GRADE classification.

RESULTS

Nutritional support, no severe pulmonary infection and weaning from mechanical ventilation were the 3 determinants for timing of operation. TEFs were classified into 3 levels: small TEF (<1 cm), moderate TEF (≥1 but <5 cm) and large TEF (≥5 cm). Fistula repair or tracheal segmental resection was used for the small TEF with normal tracheal status. If the anastomosis cannot be finished directly after tracheal segmental resection, special types of tracheal resection, such as slide tracheoplasty, oblique resection and reconstruction, and autologous tissue flaps were preferred depending upon the site and size of the fistula. Oesophageal exclusion was applicable to refractory TEF or patients with poor conditions.

CONCLUSIONS

The review primarily summarizes the main surgical techniques employed to repair various acquired TEF, to provide references that may contribute to the treatment of TEF.

Post-Intubation Tracheoesophageal Fistula: Surgical Management by Complete Cervical Tracheal Transection

We report successful surgical management of post-intubation tracheoesophageal fistula (TEF) in an adult patient requiring long-term mechanical ventilation. A complete tracheal transection without tracheal resection, via an anterior cervical approach, followed by direct closure of tracheal and esophageal defect, and interposition of muscle flap between the suture lines and tracheal reconstruction was performed. In selected cases, this surgical procedure may be a viable alternative to traditional techniques used to treat post-intubation TEF via the anterior or lateral cervical approach.

Surgical closure of enlarged tracheoesophageal fistula after laryngectomy: A systematic review of techniques

OBJECTIVES

The objectives of the study were (1) systematically review the data on surgical closure of enlarged tracheoesophageal fistula after laryngectomy and (2) to perform a comparison of reconstruction of surgical techniques.

METHODS

Systematic review was performed using PRISMA methodology. Cumulative patient data were compared between patients reconstructed with vascularized tissue (sternocleidomastoid fascia and muscle, pectoralis major, deltopectoral, radial forearm) and those closed primarily (two-layer, three-layer, and tracheal transposition).

RESULTS

Fourteen studies reported outcomes for the reconstruction of tracheoesophageal fistula. Primary closure was used in 98 patients, vascularized flap in 74, and occlusive device in 8. Vascularized flap resulted in successful closure of the fistula in 89 % of cases compared to primary closure in 62 % (p = 0.0003).

CONCLUSION

Systematic review of the literature supports an improved surgical closure rate with vascularized flap interposed between the esophageal and tracheal lumens compared to primary closure.

Prophylactic Acid-suppression Medication to Prevent Anastomotic Strictures After Oesophageal Atresia Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Anastomotic stricture is a common postoperative complication of oesophageal atresia ± tracheoesophageal fistula (OA/TOF) repair. Acid gastro-oesophageal reflux disease (GORD) is considered to be a factor in stricture formation and acid suppression medication is recommended post-operatively in consensus guidance. We aimed to investigate whether patients who were treated prophylactically with acid suppression medication had a reduced incidence of strictures compared to those who did not receive it.

METHODS

A systematic review of studies was performed, searching multiple databases without language or date restrictions. Multiple reviewers independently assessed study eligibility and literature quality. The primary outcome was anastomotic stricture formation, with secondary outcomes of GORD, anastomotic leak, and oesophagitis. Meta-analysis was performed using a random effects model, and the results were expressed as an odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

No randomised studies on the topic were identified. Twelve observational studies were included in the analysis with ten reporting the primary outcome. The quality assessment showed a high risk of bias in several papers, predominantly due to non-objective methods of assessment of oesophageal stricture and the non-prospective, non-randomised nature of the studies. Overall, 1395 patients were evaluated, of which 753 received acid suppression medication. Meta-analysis revealed a trend towards increased odds of anastomotic strictures in infants receiving prophylactic medication, but this was not statistically significant (OR 1.33; 95% CI 0.92, 1.92). No significant differences were found in secondary outcomes.

CONCLUSIONS

This meta-analysis found no evidence of a statistically significant link between the prophylactic prescribing of acid suppression medication and the risk of developing anastomotic stricture after OA repair. The literature in this area is limited to observational studies and a randomised controlled trial is recommended to explore this question.

LEVEL OF EVIDENCE

Level III.

The surgical approach of late-onset tracheoesophageal fistula in a tracheostomized COVID-19 patient

In the COVID-19 era the tracheal complications due to prolonged mechanical ventilation have significantly increased. Acquired tracheoesophageal fistula is one of those in ventilated COVID-19 patients. Thus, the knowledge of their management in such fragile patient is crucial. We report a case of tracheoesophageal fistula in a 56-year-old female under prolonged mechanical ventilation for COVID-19 bilateral pneumonia and discuss its management. A surgical approach was proposed. By a collar-shaped transverse cervicotomic access, we transected the trachea at level of fistula en-bloc with the tracheostoma. The esophageal lesion was longitudinally repaired in two-layers. Protective left strap muscle was sandwiched between esophagus and trachea. The tracheal end-to-end anastomosis was completed without a re-tracheostoma. Even if surgical approach of tracheoesophageal fistula in COVID-19 patients has not been tested before, surgery remains the treatment of choice according to the multidisciplinary board.

[Treatment of tracheoesophageal fistula and consequences of severe spinal injury]

Modern approaches to intensive care and anesthesiology make it possible to save patients with various severe traumas. Prolonged mechanical ventilation allows stabilizing the patient's status, but can result severe complications including tracheoesophageal fistula. Our patient received severe combined injury after road accident, i.e. compression-comminuted fractures of DIV, DV, DVI vertebrae with spinal cord compression, ThIII compression fracture, compression-comminuted fracture of bodies and arches ThIV, V, VI with ThVI dislocation, lower paraplegia and pelvic organ dysfunction, left-sided laryngeal paresis, brain concussion and contusion of both lungs. Mechanical ventilation has been performed for 1.5 months. The patient suffered inflammatory complications: bilateral pneumonia complicated by right-sided pleural empyema, sepsis, tracheostomy suppuration followed by cervical soft tissue abscess. Pleural drainage and debridement, as well as drainage of abscess were performed. At the same time, we diagnosed external esophageal fistula at the CVII level. Tracheoesophageal fistula closure via cervical access was carried out at the first stage. Postoperative period was uneventful. After 20 days, we performed spondylosynthesis ThI-ThVII, and decompression laminectomy ThIV-ThVI. Spine stabilization by metal elements has a beneficial effect even without spinal cord recovery regarding better conditions for neurological and social rehabilitation. Thus, treatment was performed in a highly specialized multi-field hospital by thoracic surgeons and vertebrologists. We realized the treatment plan and obtained favorable results with minimal risk of postoperative complications.

MANAGEMENT OF COMPLICATIONS FOLLOWING BUTTON BATTERY INGESTION

Ingestion of button batteries by children is increasing every year, which is becoming a clinical problem for pediatricians. The number of complications and mortality when using batteries exceeds similar indicators when accidentally swallowing other foreign bodies. This is due to the electrochemical and mechanical effect of the battery on the mucous membrane of the gastrointestinal tract and especially the esophagus. With a late diagnosis, an ordinary battery leads to the development of fatal complications. In modern literature, there are no protocols that would relate to the treatment of similar situations, in particular, in the development of a tracheoesophageal fistula. The article describes a case of successful treatment of a tracheoesophageal fistula due to a long-term stay of a battery in the esophagus. This condition was also complicated by the development of bilateral tension pneumothorax. The dilemma in such cases is always difficult: to choose operative or conservative treatment. Both methods have their advantages and disadvantages. In this clinical case, preference was given to conservative treatment, which ended quite successfully. But the main goal is to prevent such situations. This can be achieved by raising parents' awareness of the risks of battery ingestion. Also, the efforts of a doctor who is faced with a similar situation should be directed to the fastest possible diagnosis and removal of such a foreign body as a battery.

iPSCs derived from esophageal atresia patients reveal SOX2 dysregulation at the anterior foregut stage

A series of well-regulated cellular and molecular events result in the compartmentalization of the anterior foregut into the esophagus and trachea. Disruption of the compartmentalization process leads to esophageal atresia/tracheoesophageal fistula (EA/TEF). The cause of EA/TEF remains largely unknown. Therefore, to mimic the early development of the esophagus and trachea, we differentiated induced pluripotent stem cells (iPSCs) from EA/TEF patients, and iPSCs and embryonic stem cells from healthy individuals into mature three-dimensional esophageal organoids. CXCR4, SOX17 and GATA4 expression was similar in both patient-derived and healthy endodermal cells. The expression of the key transcription factor SOX2 was significantly lower in the patient-derived anterior foregut. We also observed an abnormal expression of NKX2.1 (or NKX2-1) in the patient-derived mature esophageal organoids. At the anterior foregut stage, RNA sequencing revealed the critical genes GSTM1 and RAB37 to be significantly lower in the patient-derived anterior foregut. We therefore hypothesize that a transient dysregulation of SOX2 and the abnormal expression of NKX2.1 in patient-derived cells could be responsible for the abnormal foregut compartmentalization.

Congenital adult tracheoesophageal fistula repair with transthoracic ventilation: a case report

PURPOSE

To describe our experience using transthoracic ventilation to facilitate oral endotracheal tube (ETT) exchange after accidental ETT cuff rupture during a case of congenital tracheoesophageal fistula (TEF) repair.

CLINICAL FEATURES

A 53-yr-old male underwent a congenital H-type TEF repair via right-sided thoracotomy with a single-lumen ETT and a bronchial blocker. A large air leak developed after ETT cuff rupture during fistula closure. Transthoracic intubation via tracheotomy was performed to continue ventilation during an oral ETT exchange in the lateral position. No hypoxia or hemodynamic compromise occurred.

CONCLUSIONS

Airway device choice for TEF repair must be carefully considered in conjunction with the surgical team. In the present case of accidental ETT cuff rupture, rescue transthoracic ventilation safely facilitated oral ETT exchange.

Recovery of cyanosis after esophageal intubation in a neonate with tracheal agenesis: a case report

BACKGROUND

Tracheal agenesis (TA) is a rare congenital defect that consists of a complete or partial absence of the trachea below the larynx, with or without tracheoesophageal fistula (TEF). It is a severe congenital defect with a very high mortality rate. The recommended surgical approach is esophageal ligation and gastrostomy. Despite the progress in reconstructive surgical techniques, the outcome of the anomaly is still very poor. We described a case of TA with a TEF in a female newborn with a hemivertebra, single ventricle, single atrioventricular valve, single atrium, and cardiac left isomerization.

CASE

The patient, who was born at 37 weeks of age, was diagnosed with imaging methods, as the cyanosis did not improve despite being intubated many times in the delivery room; the cyanosis improved after esophageal intubation. Despite all life support treatment, the patient died on the fourth day of life. At autopsy, tracheal agenesis was diagnosed.

CONCLUSIONS

In newborns who cannot be intubated in the delivery room or whose lungs cannot be ventilated despite being intubated and whose cyanosis cannot be corrected, tracheal agenesis should be considered and ventilation with esophageal intubation should also be tried.

[Treatment of laryngotracheal and tracheal cicatricial stenosis: 10-year experience]

OBJECTIVE

To describe 10-year experience of treating the cicatricial tracheal stenosis (CTS) in a regional multi-field hospital.

MATERIAL AND METHODS

There were 120 CTS patients aged 13-75 years. In 8 (6.7%) patients, CTS was combined with tracheoesophageal fistula (TPF). Post-intubation stenosis was diagnosed in 16 (13.3%) cases, post-tracheostomy - in 102 (85%) ones, post-traumatic - in 2 (1.7%) patients. CTS length ranged from 1.2 to 8 cm. Fifty (41.7%) patients had cervical CTS, 40 (33.3%) patients - cervico-thoracic tracheal stenosis, 11 (9.2%) patients - tracheal stenosis at the thoracic level. Nineteen (15.8%) patients had multifocal stenoses. We used endoscopic techniques, circular tracheal resection (CTR) and laryngotracheal reconstruction.

RESULTS

Postoperative mortality rate was 0.83%. CTR was performed in 33 patients, laryngotracheal reconstruction - 77, endoscopic stenting - 6 patients. In 4 cases, local CTS was eliminated by bougienage and argon plasma exposure. CTS was successfully disconnected with TEF using CRT in 3 cases, laryngotracheoplasty and stenting - in 5 cases. The fenestrated tracheal defect was closed by a three-layer autologous flap in 59 patients. Of these, autologous flap was reinforced with porous nickel-titanium implants in 17 patients. Postoperative complications after CRT occurred in 6 (16.7%) patients (anastomotic leakage - 2, anastomositis - 1, restenosis - 2). No patients died. Postoperative complications after laryngotracheal reconstruction were observed in 18 (23.4%) patients including 5 ones with restenosis who underwent CTR with a favorable outcome.

CONCLUSION

CTS treatment requires a multidisciplinary approach. Each surgery has certain indications and place in treatment algorithm. CTR is highly effective, but may be accompanied by complications associated with tracheal anastomosis. Decrease of postoperative morbidity will improve immediate and long-term results of CTS treatment. The chosen treatment algorithm ensured good and satisfactory results in 98% of patients.

Identification of acquired tracheoesophageal fistula after tracheostomy decannulation by videofluoroscopic swallowing study: A case report

RATIONALE

Videofluoroscopic swallowing study (VFSS) is a noninvasive radiographic procedure that examines the oral, pharyngeal, and cervical esophageal stages of swallowing. Tracheoesophageal fistula (TEF) is difficult to diagnose depending on its size and location. However, how VFSS can be of benefit in the diagnosis of TEF has not been reported yet.

PATIENT CONCERNS

A 64-year-old man who had been tracheostomized post spinal tumor resection surgery at the cervical level 1 to 2, had his tracheostomy tube removed approximately 25 years ago. After decannulation, he reported coughing while swallowing food, foreign sensation in the neck and repeated bouts of pneumonia ever since.

DIAGNOSIS

VFSS revealed, for the first time, acquired TEF after tracheostomy decannulation as the cause of repetitive aspiration pneumonia.

INTERVENTION

VFSS was performed in this case.

OUTCOMES

In the background of suspected TEF based on VFSS results, the patient underwent a computed tomography scan of the chest and airway in the prone position, followed by bronchoscopy, which confirmed the existence of a TEF. He then underwent primary closure of the fistula. The patient had an uneventful recovery and is currently symptom-free 10 months after the surgery.

LESSONS

This case alerts clinicians to the possibility of TEF as a diagnosis when the aspirate leaks from the upper esophagus and through the posterior wall of trachea in the esophageal phase of VFSS.

Tracheoesophageal Fistula Complicated by Iatrogenic Gastric Perforation in a Low Birth Weight Neonate

Type-III tracheoesophageal fistula is the commonest type of fistula where upper pouch is blind and distal oesophageal pouch communicates with trachea. In this condition, gastric distension is a common manifestation which can be worsened by positive pressure ventilation. Pulmonary pathology may necessitate ventilation with high peak airway pressures which may rarely lead to gastric perforation with serious consequences. We are reporting such a case of gastric perforation during ventilatory management for fistula repair which needed surgical repair. Keywords: Airway management; esophageal atresia; gastric perforation; tracheo-oesophageal fistula.

Tracheoesophageal fistula associated with bevacizumab after thoracic radiotherapy in non-small cell lung cancer: A case report

INTRODUCTION

Tracheoesophageal Fistula (TF) is a rare complication of Bevacizumab. Thoracic radiotherapy may be a contributing factor to TF formation. To the best of our knowledge, we report the first case of Chinese patient with non-small cell lung cancer (NSCLC) who developed TF after completion of chemotherapy with bevacizumab and thoracic radiotherapy.

PATIENT CONCERNS

A 54-year-old male patient was diagnosed with NSCLC. He received definitive thoracic radiotherapy with concurrent pemetrexed and cisplatin chemotherapy. Two months after the treatment, the disease progressed with enlargement of right inguinal lymph node and chemotherapy of docetaxel, carboplatin and bevacizumab was administrated. Eighteen days after 4 cycles, the patient presented a sudden onset of acute cough after drinking.

DIAGNOSIS

Esophageal barium swallow revealed a TF. Gastroscopy confirmed a fistula in the esophagus.

INTERVENTIONS

A jejunal feeding tube was placed for nutrition for a month. After that a covered esophageal stent was placed in the esophagus.

OUTCOMES

At the 6-month follow-up visit, the patient recovered well and had not developed any complication related to the stent placement.

CONCLUSION

TF is a rare but life-threatening complication of bevacizumab. Careful observation is imperative for those patients who are administered bevacizumab, particularly in patients treated previously with thoracic radiotherapy.

Novel magnetic compression technique for establishment of a canine model of tracheoesophageal fistula

BACKGROUND

Clinically, tracheoesophageal fistula (TEF) is lack of effective surgical strategies. One reason is due to the lack of appropriate animal models of acquired TEF, which is usually complex and difficult. Recently, the magnetic compression technique has been applied for digestive tract anastomosis or vascular anastomosis in animals. In this study, an animal model of TEF in dogs was developed by using the magnetic compression technique, hoping to provide a new method for mimicking TEF.

AIM

To establish a TEF model in dogs by using the magnetic compression technique.

METHODS

Six male beagles were used as models with two Nd-Fe-B permanent magnets for TEF. The parent magnet and the daughter magnet were placed in the cervical esophagus and trachea, respectively. The anterior wall of the esophagus and the posterior wall of the trachea were compressed when the two magnets coupled. After 4-6 d, the necrotic tissue between the two magnets fell off and the parent and daughter magnets disengaged from the target location, leaving a fistula. Gastroscopy/bronchoscopy, upper gastrointestinal contrast study, and histological analysis were performed.

RESULTS

The establishment of the TEF model in all six beagles was successful. The average time of magnet placement was 4.33 ± 1.11 min (range, 3-7 min). Mean time for the magnets to disengage from the target location was 4.67 ± 0.75 d (range, 4-6 d). TEFs were observed by gastroscopy/bronchoscopy and esophageal angiography. The gross anatomical structure of the esophagus and the trachea was in good condition. There was no esophageal mucosa or pseudostratified ciliated columnar epithelium at the site of the fistula according to histological analysis.

CONCLUSION

It is simple, feasible, and minimally invasive to use the magnetic compression technique for the establishment of the TEF model in dogs.

Prolonged Intubation Induced Tracheoesophageal Fistula in Suspected Meningococcal Sepsis with ARDS: A Case Report

Tracheoesophageal fistula is an abnormal communication between trachea and esophagus. Benign acquired types are rare with the incidence of less than 1%. Prolonged endotracheal intubation remains the most common cause. We are reporting a 28 years old female patient presented with chief complaint of a cough after each meal intake in the outpatient clinic. She had a recent history of admission in the intensive care unit with prolonged intubation (11 days). Her general physical examination, laboratory examination, and chest x-ray were normal. Esophagogastroscopy was performed and revealed communication between upper esophagus and trachea approximately at 14–17cm embedded in longitudinal mucosal folds of the esophagus. She was referred to the higher center for surgical repair. Though, a rare complication, high suspicion is necessary to accurately diagnose the disease in a patient with the history of prolonged intubation.

Postintubation Tracheoesophageal Fistula - Diagnosis, Treatment and Prognosis

Introduction: Postintubation tracheoesophageal fistula is a severe complication occurring under certain conditions in patients that require prolonged mechanical ventilation.

MATERIAL AND METHODS

This article focuses on a sample of 11 patients with postintubation tracheoesophageal fistula, operated in our department between 2005 and 2015. The anterior approach with tracheal resection was performed in 10 of these patients, while an atypical surgical technique was preferred in a case involving a large-sized fistula. Three of these patients were subject to surgery while still on the ventilator, in order to help weaning them from mechanical ventilation. Two patients were operated following a relapse of the fistula, after attempts of closing it in other surgical units. Results: Two patients (of those who were still on mechanical ventilation) died from intubation-related complications that persisted after tracheal resection (anastomotic dehiscence with mediastinitis and tracheoarterial fistula in the brachiocephalic arterial trunk). The nine remaining patients improved, with their airways restored and having regained normal deglutition. Conclusions: The surgical approach of this pathology is successful in surgical units that are specialised in tracheal and oesophageal surgery. Adequately timing the surgery is crucial for a good outcome.

Predictors of post-treatment stenosis in cervical esophageal cancer undergoing high-dose radiotherapy

AIM

To evaluate toxicity and treatment outcome of high-dose radiotherapy (RT) for cervical esophageal cancer (CEC).

METHODS

We reviewed a total of 62 consecutive patients who received definitive RT for stage I to III cervical esophageal cancer between 2001 and 2015. Patients who received < 45 Gy, treated for lesions below sternal notch, treated with palliative aim, treated with subsequent surgical resection, or diagnosed with synchronous hypopharyngeal cancer were excluded. Treatment failures were divided into local (occurring within the RT field), outfield-esophageal, and regional [occurring in regional lymph node(s)] failures. Factors predictive of esophageal stenosis requiring endoscopic dilation were analyzed.

RESULTS

Grade 1, 2, and 3 esophagitis occurred in 19 (30.6%), 39 (62.9%), and 4 patients (6.5%), respectively, without grade ≥ 4 toxicities. Sixteen patients (25.8%) developed post-RT stenosis, of which 7 cases (43.8%) were malignant. Four patients (6.5%) developed tracheoesophageal fistula (TEF), of which 3 (75%) cases were malignant. Factors significantly correlated with post-RT stenosis were stage T3/4 (P = 0.001), complete circumference involvement (P < 0.0001), stenosis at diagnosis (P = 0.024), and endoscopic complete response (P = 0.017) in univariate analysis, while complete circumference involvement was significant in multivariate analysis (P = 0.003). A higher dose (≥ 60 Gy) was not associated with occurrence of post-RT stenosis or TEF. With a median follow-up of 24.3 (range, 3.4-152) mo, the 2 y local control, outfield esophageal control, progression-free survival, and overall survival (OS) rates were 78.9%, 90.2%, 49.6%, and 57.3%, respectively. Factors significantly correlated with OS were complete circumference involvement (P = 0.023), stenosis at diagnosis (P < 0.0001), and occurrence of post-RT stenosis or TEF (P < 0.001) in univariate analysis, while stenosis at diagnosis (P = 0.004) and occurrence of post-RT stenosis or TEF (P = 0.023) were significant in multivariate analysis.

CONCLUSION

Chemoradiation for CEC was well tolerated, and a higher dose was not associated with stenosis. Patients with complete circumferential involvement require close follow-up.

Pierre Robin Sequence with Esophageal Atresia and Congenital Radioulnar Synostosis

A wide spectrum of anomalies can be associated with Pierre Robin sequence. This report presents a 3-day-old infant with micrognathia, U-shaped cleft palate, low-set right ear with microtia, glossoptosis, esophageal atresia, and right congenital radioulnar synostosis. The association of congenital radioulnar synostosis and esophageal atresia with Pierre Robin sequence has not been previously described.

Esophageal atresia with distal fistula - unusual case series. Considerations related to epidemiological aspects, malformative associations, and prenatal diagnosis

BACKGROUND

Esophageal atresia (EA) is the most frequent and severe congenital anomaly of the esophagus, occurring in 1:2500-1:4500 live births. Five types of EA have been described, EA with tracheoesophageal fistula (TEF) being the most frequent.

AIM

The aim of this paper is to evaluate epidemiological aspects, malformative associations, and prenatal diagnosis in an unusual case series of EA with distal TEF.

CASE PRESENTATIONS

The authors are analyzing a series of seven cases of EA with distal TEF. The seven cases of EA with TEF presented occurred during a period of two years, resulting in an unusually increased rate - 1.1:1000 live births. Except a late suspicion of EA (one day before delivery), EA was not diagnosed during prenatal scans despite association with polyhydramnios in two cases and single umbilical artery in four cases. None of the two cases of unilateral renal agenesis or anorectal malformations were diagnosed on prenatal ultrasound scans. In two of the cases, EA was part of VACTERL (vertebral defects, anorectal malformations, heart defects, EA with or without TEF, renal anomalies/dysplasia, and limb defects) association. Despite lack of prenatal diagnosis, postnatal diagnosis of EA was suspected at birth in four cases, at two hours in one case.

CONCLUSIONS

An increased index of suspicion for congenital structural defects, particularly for EA, should be maintained in the presence of a single umbilical artery and÷or polyhydramnios on prenatal ultrasound scan. Prenatal diagnosis of EA offers the chance for parental counseling, planned birth and transfer for corrective surgery and decreases the risk for postnatal aspiration pneumonia associated with early feedings.

[Patient-related independent clinical risk factors for early complications following interventional pulmonology procedures]

OBJECTIVE

To investigate the early complication rate and identify patient-related independent clinical risk factors for early complications in patients following interventional pulmonology procedures.

METHODS

In the period from December 2014 to December 2015, sufficient data of Peking University First Hospital Respiratory and Critical Care Medicine Department for analysis were identified in 218 subjects. Interventional pulmonology procedures were performed in all the patients. Early complications after the procedures were defined as newly respiratory failure, arrhythmia requiring treatment, severe hemoptysis, pneumothorax, pneumomediastinum, pulmonary edema, tracheoesophageal fistulae, bronchopleural fistulae, acute coronary syndrome, acute cerebrovascular accident, and death. Patient-related clinical risk factors were defined as coronary atherosclerotic heart disease, cerebral infarction, diabetes mellitus, cirrhosis, chronic kidney disease, arrhythmia, asthma, chronic obstructive pulmonary disease, hypertension, and previous interventional pulmonology treatment. The patient-related independent clinical risk factors which had close relations to the occurrence of early complications were analyzed by multivariate statistical analysis with Logistic regression.

RESULTS

There were 56.4% male and 43.6% female subjects in this study. There were 10.6% current smokers, 26.6% former smokers, and 62.8% non-smokers. The overall early complication rate was 8.3%. In all the subjects groups, the patient-related independent clinical risk factors for the early complication rate were coronary atherosclerotic heart disease (B=1.545, P=0.006, OR=4.686, 95% CI 1.568-14.006), chronic obstructive pulmonary disease (B=1.037, P=0.049, OR=2.820, 95% CI 1.675-11.790), and current smoking status (B=1.412, P=0.032, OR=4.139, 95% CI 1.134-15.109); for the newly respiratory failure rates were coronary atherosclerotic heart disease (B=2.207, P=0.004, OR=9.087, 95% CI 2.028-40.714), chronic obstructive pulmonary disease (B=1.646, P=0.048, OR=5.188, 95% CI 1.783-34.375), and lesions involving three central airways (B=1.899, P=0.032, OR=6.680, 95% CI 1.182-37.740). In the malignant group, the patient-related independent clinical risk factor for the early complication rate was current smoking status (B=2.953, P=0.006, OR=19.161, 95% CI 2.360-155.572). In the benign group, the patient-related independent clinical risk factor for the early complication rate was only coronary atherosclerotic heart disease (B=1.976, P=0.022, OR=7.214, 95% CI 1.324-39.298).

CONCLUSION

Closer monitoring of patients with identified clinical risk factors is advisable prior and immediately after interventional pulmonology procedures. In order to avoid or minimize early complications, special attention should be directed toward patients who are current smokers, or patients with lesions involving three central airways, or with coronary atherosclerotic heart disease or chronic obstructive pulmonary disease.

Tracheoesophageal Fistula following Endotracheal Intubation for Organophosphorus Poisoning

Tracheoesophageal fistula (TEF) is an abnormal communication between the trachea and esophagus. Iatrogenic TEF can be due to endotracheal intubation, rigid bronchoscopy or tracheostomy. Tracheostomy tube cuff volumes and pressures require constant monitoring to avoid tracheal injury. Acquired TEF which occurs after prolonged intubation, usually develops after 15-200 days of mechanical ventilation. We report a case of a large TEF secondary to endotracheal intubation for organophosphorus poison-induced respiratory failure. Patient presented with dysphagia and recurrent aspiration pneumonia after extubation. She underwent trachea-esophageal fistulectomy and closure with a sternocleidomastoid muscle flap.

Repair of large airway defects with bioprosthetic materials

OBJECTIVE

Patients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of this study was to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects.

METHODS

Retrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic device, namely aortic homograft or acellular dermal matrix.

RESULTS

Eight patients, 3 men and 5 women with a mean age of 54 ± 13 years, underwent closure of complex central airway defects with bioprosthetic material. All but 1 patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, whereas 5 had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n = 5), the anterior wall of the trachea (n = 1), or the main stem bronchus (n = 2). Five reconstructions were with aortic homograft and 3 with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n = 4), omentum (n = 2), or left unbuttressed (n = 2). The airway defect was successfully closed in all patients. There was no postoperative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and 1 additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%).

CONCLUSIONS

Bioprosthetic materials represent a viable option for management of large airway defects, including airway-enteric fistulae, that exceed the limits of primary repair.

[INTENSIVE THERAPY OF THE PATIENT WITH VIRAL-BACTERIAL PNEUMONIA, PROLONGED VENTILATION (137 DAYS) AND TRACHEOESOPHAGEAL FISTULA]

A case of successful therapy of the patient with viral and bacterial pneumonia, prolonged ventilation (137 days) and tracheoesophagealfistula presented. The possibility of optimizing the gas exchange in the lungs by selecting appropriate modes of mechanical ventilation with the use ofproportional assist ventilation of the lungs (PVVL or PAV +), rather than suppressing patient's own attempts is shown.

FOREIGN BODY INDUCED TRACHEOESOPHAGEAL FISTULA IN A PEDIATRIC PATIENT WITH A MISDIAGNOSIS: CASE REPORT AND REVIEW OF LITERATURE

Acquired tracheoesophageal fistulae can be diagnosed clinically by features such as cough elicited by swallowing but symptoms can be mild. Here, we report a case of a foreign body induced trachea-esophageal fistula in a 2 year and 6 months old male child with a chronic cough who had long been misdiagnosed and mismanaged.

[Not Available]

It is presented a 48 year-old male patient with antecedent of a foreign body intake (a beer metallic top) 4 years ago, who rejected surgery at first previous a failed attempt of endoscopic extraction. Four years later he was admitted in the Thorax National Institute in an emergency, with acute respiratory failure and sepsis signs that were corrected quickly; later on after failed surgical attempts of trachea-esophageal fistula correction and extraction of the foreign body, the patient was sent to BJIG where the endoscopic extraction of the foreign body located in the trachea was carried out together with the correction of the trachea-esophageal fistula by means of implantation, in esophagus, of covered self-expanding prosthesis.

Management of esophageal stenting-associated esophagotracheal fistula, tracheal stenosis and tracheal rupture: a case report and review of the literature

OBJECTIVE

Although the placement of esophageal self-expandable stents (SES) can effectively relieve dysphagia after radiotherapy in patients with esophageal cancer (EC), it may induce severe esophageal complications. This article reports a case of emergency endotracheal intubation in an EC patient who suddenly developed severe dyspnea two months after SES placement.

METHODS

Electronic bronchoscopy of the patient's airway confirmed the diagnosis of esophagotracheal fistula, tracheal stenosis and tracheal rupture. Endotracheal intubation was successfully performed under the guidance of electronic bronchoscopy.

RESULTS

Dyspnea due to tracheal stenosis was relieved effectively by inserting the tracheal catheter to a proper place under the guidance of electronic bronchoscopy.

CONCLUSION

Bronchoscopic examination is strongly recommended in EC patients who are highly suspected as having airway stenosis associated with esophageal stenting, for which endotracheal intubation under the guidance of bronchoscopy is suggested.

[Clinical analysis of severe complications induced by esophageal foreign bodies]

OBJECTIVE

To investigate the clinical characteristics and treatment strategies of severe complications induced by esophageal foreign bodies.

METHODS

The clinical data of 44 patients with severe complications of esophageal foreign bodies treated from July 2004 to July 2014 were retrospectively analyzed. The type of complications was recorded.

RESULTS

The ratio of severe complications in patients with esophageal foreign bodies was 9.05% (44/486). The most common type of foreign body was animal bone, with a total of 34 cases (77.3%); Onset of the disease were 2-40 days, mostly above 6 days, accounting for 61.4%. Severe complications of esophageal foreign bodies included 16 cases (36.3%) of simple esophageal perforation or combined with esophageal regional inflammation, 14 cases (31.8%) of cervical abscess, 7 cases (15.9%) of abscess around esophagus, 3 cases (6.8%) of mediastinal abscess, one case (2.3%) of cervical subcutaneous emphysema, one case of tracheoesophageal fistula, one case (2.3%) of aortic fracture, and one case (2.3%) of subclavian artery pseudoaneurysm. Among the 44 patients with severe complications, 40 patients (90.9%) were cured and 3 patients (6.8%) died. One case didn't receieve treatment.

CONCLUSIONS

Occurrence of the severe complications induced by esophageal foreign bodies is closely related to the type of foreign bodies and time before presentation. Early diagnosis and prompt treatments for esophageal foreign bodies are crucial for preventing of severe complications.

Esotracheal Fistula in Esophageal Stenoses of Malignant Origin - Case Report

BACKGROUND

Approximately 80% of acquired eso-tracheal or mediastinal fistulae are of malignant nature. The occurrence of an eso-respiratory malignant fistula is a devastating complication for both patient and doctor, and, if not treated, records a survival time of 1 to 6 weeks.

MATHERIAL AND METHOD

We present a patient, aged 51, smoker,with progressive dysphagia, at first to solids, then to semi-solids and liquids, followed by manifestation of post-deglutition cough due to eso-tracheal fistula, incapability of feeding, and decline of the general condition. Surgical intervention consists of esophageal transstenotic endo-prosthesing by transtumoral drilling with prosthetic montage and the occlusion of the eso-tracheal fistulous orifice.

RESULTS

The post-operatory evolution is favorable, the feeding per os resumes in 8 hours after surgery, good digestive tolerance. The radiologic examination using contrast medium, performed in 48 hours after surgery, reveals a permeable esophageal endo-prosthesis, without reflux of contrast substance in the tracheobronchial tree.

CONCLUSIONS

The laparo-gastroscopic montage of prosthesis through transtumoral drilling, using siliconized semi-rigid prostheses, represents the only efficient palliative treatment of malignant eso-tracheal or eso-bronchial fistula.

Aerodigestive fistula formation as a rare side effect of antiangiogenic tyrosine kinase inhibitor therapy for thyroid cancer

BACKGROUND

In the past decade, targeted therapy with antiangiogenic drugs has become standard of care for most types of metastatic, progressive thyroid cancer. While these drugs were thought initially to be less toxic than traditional chemotherapy, they can have rare but serious and fatal toxicities. Once such toxicity that has been reported in other tumor types is upper airway fistula formation, which can be life-threatening.

SUMMARY

Here, we describe three patients treated with antiangiogenic tyrosine kinase inhibitors at two academic institutions who developed aerodigestive fistula. All three patients had risk factors for fistula formation, which included external beam radiation and/or large tumor with invasion of the tracheal wall.

CONCLUSIONS

Fistula formation is a known but rare side effect of antiangiogenic tyrosine kinase inhibitors. Knowledge of the risk factors that may predispose thyroid cancer patients to this serious adverse event is vital prior to prescribing antiangiogenics. Particular caution should be observed when using these drugs in patients undergoing radiation therapy or surgery, or in patients whose tumor is invading vital structures of the neck, as they may be at higher risk of developing this rare complication. In these patients, antiangiogenic tyrosine kinase inhibitors should be used cautiously, patients should be aware of the risk, and physicians should monitor patients for symptoms of fistula.

[Esophageal stenting complications]

The aim of the study was to analyze esophageal stenting complications in case of cancer and benign diseases. It was investigated complications in 8 patients in terms from 7 days to 1 year after intervention. In 4 patients esophageal stenting was performed for constrictive esophageal cancer and compression with pulmonary cancer metastases into mediastinal lymphatic nodes. 2 patients had esophageal stenting for post-tracheostomy tracheo-esophageal fistula, 1 patient - for spontaneous esophageal rupture, 1 patient - for post-burn scar narrowing of esophagus and output part of the stomach. Severe patients' condition with tumor was determined by intensive esophageal bleeding in 2 cases, bilateral abscessed aspiration pneumonia, tumor bleeding, blood aspiration (1 case), posterior mediastinitis (1 case). Severe patients' condition with benign disease was associated with decompensated esophageal narrowing about proximal part of stent (1 case), increase of tracheo-esophageal fistula size complicated by aspiration pneumonia (1 case), stent migration into stomach with recurrence of esophago-mediastino-pleural fistula and pleural empyema (1 case), decompensated narrowing of esophagus and output part of the stomach (1 case). Patients with cancer died. And patients with benign diseases underwent multi-stage surgical treatment and recovered. Stenting is palliative method for patients with esophageal cancer. Patients after stenting should be under outpatient observation for early diagnosis of possible complications. Esophageal stenting in patients with benign diseases should be performed only by life-saving indications, in case of inability of other treatment and for the minimum necessary period.

[A case of large tracheoesophageal fistula after repair of the right discending aortic arch]

A 77-year-old woman with right aortic arch was diagnosed as aortic dissection (De Bakey IIIb) and hospitalized for conservative treatment. But, her respiratory condition deteriorated due to tracheal stenosis with aortic dissection. Surgical graft replacement of the descending aorta was performed to release tracheal stenosis. Six days after surgery, tracheoesophageal fistula (TEF) was noticed. The size of the fistula was 3 cm in diameter, located 3cm to the oral side from the carina and 23 cm from the incisors. Nineteen days after surgery, an esophageal stent was placed leading to temporary improvement of the respiratory status, but it aggravated again. Unfortunately, she died due to ventricular fibrillation 26 days after surgery. The case is extremely rare with dissection of the right aortic arch. Such a case is considered to be a high risk of TEF, and it is necessary to perform early preventive measures.

[Iatrogenic trachea and esophagus injury in intensive care practice: the surgeon's view"]

From 1963 to 2011 in the Department of lung and mediastinum surgery were treated 879 patients with trachea stenosis and 107 patients with benign tracheoesopageal fistula were treated in the Department of lung and mediastinum surgery from 1963 to 2011. latrogenic trachea and the esophagus damage was caused by long-term ALV in 87% of cases. Patients were aged from 5 to 79 years. 47.2% of patients came with functioning tracheostome. 25.7% of patients had a clinically significant respiratory disorder at admission, 10.2 % of which were life-threatening. Iatrogenic damage of the trachea was identified before extubation or decannulation only in 27% of patients. In such circumstances, prevention and diagnostics of iatrogenic injuries, as well as initial care alternatives takes on special significance.

Endoscopic stent insertion for anastomotic leakage following oesophagectomy

INTRODUCTION

Intrathoracic anastomotic leakage following oesophagectomy is a crushing condition. Until recently, surgical re-exploration was the preferred way of dealing with this life threatening complication. However, mortality remained significant. We therefore adopted endoscopic stent implantation as the primary treatment option. The aim of this study was to investigate the feasibility and results of endoscopic stent implantation as well as potential hazards and pitfalls.

METHODS

Between January 2004 and December 2011, 292 consecutive patients who underwent an oesophagectomy at a single high volume centre dedicated to oesophageal surgery were included in this retrospective study. Overall, 38 cases with anastomotic leakage were identified and analysed.

RESULTS

A total of 22 patients received endoscopic stent implantation as primary treatment whereas a rethoracotomy was mandatory in 15 cases. There were no significant differences in age, frequency of neoadjuvant therapy or ASA grade between cases with and without a leak. However, patients with a leak were five times more likely to have a fatal outcome (odds ratio: 5.10, 95% confidence interval: 2.06-12.33, p<0.001). Stent migration occurred but endoscopic reintervention was feasible. In 17 patients (77%) definite closure and healing of the leak was achieved, and the stent was removed subsequently. Two patients died owing to severe sepsis despite sufficient stent placement. Moreover, stent related aortic erosion with consecutive fatal haemorrhage occurred in three cases.

CONCLUSIONS

Stent implantation for intrathoracic oesophageal anastomotic leaks is feasible and compares favourably with surgical re-exploration. It is an easily available, minimally invasive procedure that may reduce leak related mortality. However, it puts the already well-known risk of stent-related vascular erosion on the spot. Awareness of this life threatening complication is therefore mandatory.

[Tracheoesophageal fistulae: the state of art]

The article summarizes the experience of treatment of 107 patients with tracheoesophageal fistula of nonneoplastic etiology. Etiology, diagnostic and treatment approaches were analyzed and compared, depending on the time period. The proportion of patients with combined pathology as tracheoesophageal fistula and cicatrical stenosis of the trachea has significantly increased recently. The main cause of fistulation was the jatrogenic tracheal injury during the mechanical lung ventilation. Basic diagnostic methods were endoscopy and computed tomography. The main objective of emergency remains isolation of the tracheobronchial tree from the gastrointestinal tract. Radical surgery can cure 97.8% of patients with minimal risk, including comorbidity. Conservative treatment and palliative surgery should be used only in case of the curative treatment failure or on the preparatory stage.

[Usefulness of esophageal stenting for esophagorespiratory fistula with esophageal cancer]

We evaluated the outcome of esophageal stenting for esophagorespiratory fistula in patients with advanced esophageal cancer. Six patients with such fistula underwent esophageal stenting at our department from January 2000 to May 2012. Intraoral ingestion improved in all patients. Cough decreased immediately after stenting in 3 patients, and pneumonia detected by chest radiography improved within 1 week in 2 patients. Ventilation was weaned 2 days after stenting in 1 patient. The median survival duration after stenting was 31 days, and the cause of death was cancer in all patients. The following background factors were identified at the time of death: bleeding(n=3), mediastinitis(n=1), and pneumonia(n=1). Esophageal stenting, which should always be performed with the informed consent of the patient, improves respiratory symptoms, intraoral ingestion, and quality of life. Therefore, it is one of the best palliative therapies for patients with esophagorespiratory fistula associated with advanced esophageal cancer.

Comparative study of esophageal stent and feeding gastrostomy/jejunostomy for tracheoesophageal fistula caused by esophageal squamous cell carcinoma

BACKGROUND

A malignant tracheoesophageal/bronchoesophageal fistula (TEF) is a life-threatening complication of esophageal squamous cell carcinoma. A feeding gastrostomy/jejunostomy had been the most common treatment method for patients with TEF before the era of stenting. The aim of this retrospective study is to compare the prognosis of esophageal squamous cell carcinoma patients with TEF treated with an esophageal metallic stent to those treated with a feeding gastrostomy/jejunostomy.

METHODS

We retrospectively reviewed a total of 1011 patients with esophageal squamous cell carcinoma between 1996 and 2011 at Kaohsiung Chang Gung Memorial Hospital, and 86 patients with TEF (8.5%) were identified. The overall survival and other clinical data were compared between 30 patients treated with an esophageal metallic stent and 35 patients treated with a feeding gastrostomy/jejunostomy.

RESULTS

Among the 65 patients receiving either an esophageal metallic stent or a feeding gastrostomy/jejunostomy, univariate analysis showed that treatment modality with an esophageal metallic stent (P = 0.007) and radiotherapy treatment after fistula diagnosis (P = 0.04) were predictive of superior overall survival. In the multivariate comparison, treatment modality with an esophageal metallic stent (P = 0.026, odds ratio: 1.859) represented the independent predictive factor of superior overall survival. There were no significant differences between groups in mean decrease in serum albumin or mean body weight loss. Compared to the feeding gastrostomy/jejunostomy group, a significantly higher proportion of patients in the stenting group (53% versus 14%, P = 0.001) were able to receive chemotherapy within 30 days after fistula diagnosis, indicating better infection control in the stenting group.

CONCLUSIONS

Compared with a feeding gastrostomy/jejunostomy, an esophageal metallic stent significantly improves overall survival in patients with malignant TEF in our retrospective analysis. Esophageal metallic stent placement may be considered the first-line of treatment for patients with malignant TEF.