Management of fistulas in the upper gastrointestinal tract.

Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.

Prognostic factors for esophageal respiratory fistula in unresectable esophageal squamous cell carcinoma treated with radiotherapy.

Limited studies have focused on the prognostic factors of esophageal respiratory fistula (ERF) associated with radiotherapy in patients with unresectable esophageal squamous cell carcinoma (ESCC). Between January 1st, 2014 and January 1st, 2021, we included patients who were initially diagnosed with unresectable ESCC and underwent radiotherapy. All patients were followed up for a period of 2 years after completing their radiotherapy treatment. The primary outcomes of the study were defined as death or severe adverse events. The survival curves of ERF were calculated using the Kaplan-Meier method. Cox proportional hazards model was employed to calculated the prognostic factors. A cohort of 232 patients underwent radiotherapy, of whom 32 patients experienced ERF. The median period from initial diagnosis of ESCC to ERF was 5.75 months, and the median period from ERF to the primary outcome was 4.6 weeks. Neck + upper chest location (odds ratio [OR] 3.305), high T stage (OR 1.765), esophageal stenosis (OR 1.073), high neutrophil to lymphocyte ratio (NLR) (OR 1.384) and platelet to lymphocyte ratio (PLR) (OR 1.765) were risk factors for the occurrence of ERF. Cox regression analysis suggested that tumor location (hazards ratio [HR] 3.572, 95% confidence interval [CI] 2.467-5.1), high T stage (HR 4.050, 95% CI 2.812-5.831), esophageal stenosis (HR 2.643, 95% CI 1.753-3.983), high PLR (HR 2.541, 95% CI 1.868-3.177) were independent prognostic factors for poor survival. Esophageal stenosis, neck + upper chest tumor location, high T stage and PLR predicted the prognosis of ERF in ESCC patients undergoing radiotherapy.

Surgical repair of an aortoesophageal fistula after salvage thoracic endovascular aortic repair: a case report.

BACKGROUND: An aortoesophageal fistula can prove to be fatal. Salvage thoracic endovascular aortic repair as a bridging therapy and radical surgery with thoracotomy should be considered while treating aortoesophageal fistula without spontaneous closure. Moreover, it is essential to select a technique that reduces the risk of reinfection. Here we report a rare case of a ruptured thoracic aortic aneurysm related to esophageal perforation by a fish bone that led to massive hematemesis and shock, and the surgical treatment of an aortoesophageal fistula that developed after salvage thoracic endovascular aortic repair. CASE PRESENTATION: A 70-year-old Japanese female patient was admitted with hematemesis, thoracic pain, and shock related to esophageal perforation of a ruptured descending aortic aneurysm caused by fish bone aspiration and esophageal perforation 1 month previously. An emergency thoracic endovascular aortic repair was performed. Postoperatively, an aortoesophageal fistula that remained open and a food intake-related increase in the inflammatory response was noted. Radical blood-vessel prosthesis implantation and fistula closure were performed. The patient's postoperative course was favorable and the patient was discharged 22 days after the blood vessel prosthesis implantation. CONCLUSION: Such a case of rupture of a descending aortic aneurysm related to perforation by a fish bone and an aortoesophageal fistula is considerably rare. Thus, we report the therapeutic strategy of this particular case and review the relevant literature.

Severe Periprocedural Complications After Ablation for Atrial Fibrillation: An International Collaborative Individual Patient Data Registry.

BACKGROUND: Catheter ablation for atrial fibrillation (AF) including pulmonary vein isolation and possibly further substrate ablation is the most common electrophysiological procedure. Severe complications are uncommon, but their detailed assessment in a large worldwide cohort is lacking. OBJECTIVES: The aim of this study was to determine the incidence of periprocedural severe complications and to provide a detailed characterization of the diagnostic evaluation and management of these complications in patients undergoing AF ablation. METHODS: Individual patient data were collected from 23 centers worldwide. Limited data were collected for all patients who underwent catheter ablation, and an expanded series of data points were collected for patients who experienced severe complications during periprocedural follow-up. Incidence, predictors, patient characteristics, management details, and overall outcomes of patients who experienced ablation-related complications were investigated. RESULTS: Data were collected from 23 participating centers at which 33,879 procedures were performed (median age 63 years, 30% women, 71% radiofrequency ablations). The incidence of severe complications (n = 271) was low (tamponade 6.8‰, stroke 0.97‰, cardiac arrest 0.41‰, esophageal fistula 0.21‰, and death 0.21‰). Age, female sex, a dilated left atrium, procedure duration, and the use of radiofrequency energy were independently associated with the composite endpoint of all severe complications. Among patients experiencing tamponade, 13% required cardiac surgery. Ninety-three percent of patients with complications were discharged directly home after a median length of stay of 5 days (Q1-Q3: 3-7 days). CONCLUSIONS: This large worldwide collaborative study highlighted that tamponade, stroke, cardiac arrest, esophageal fistula, and death are rare after AF ablation. Older age, female sex, procedure duration, a dilated left atrium, and the use of radiofrequency energy were associated with severe complications in this multinational cohort. One in 8 patients with tamponade required cardiac surgery.

Purulent Pericarditis as the First Manifestation of Esophageal Carcinoma.

INTRODUCTION: Purulent pericarditis secondary to esophago-pericardial fistula is a serious complication that has been previously reported in patients with esophageal cancer treated with radio/chemotherapy and esophageal stenting. However, the presence of esophago-pericardial fistula as the first manifestation of advanced carcinoma of the esophagus is exceedingly infrequent. We report the case of a 61-year-old male who presented with sepsis, cardiac tamponade and septic shock who was found to have an esophago-pericardial fistula secondary to squamous carcinoma of the esophagus. Emergency pericardiocentesis was performed with subsequent hemodynamic improvement. The drained pericardial fluid was purulent in nature and cultures were positive for Streptococcus anginosus. A CT scan followed by upper gastrointestinal endoscopy with tissue biopsy confirmed the diagnosis of squamous cell carcinoma of the esophagus. A self-expanding covered stent was endoscopically placed to exclude the fistula and restore the esophageal lumen. In this report, we discuss some aspects related to the diagnosis and management of this serious clinical entity.

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization.

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

Prediction of malignant esophageal fistula in esophageal cancer using a radiomics-clinical nomogram.

BACKGROUND: Malignant esophageal fistula (MEF), which occurs in 5% to 15% of esophageal cancer (EC) patients, has a poor prognosis. Accurate identification of esophageal cancer patients at high risk of MEF is challenging. The goal of this study was to build and validate a model to predict the occurrence of esophageal fistula in EC patients. METHODS: This study retrospectively enrolled 122 esophageal cancer patients treated by chemotherapy or chemoradiotherapy (53 with fistula, 69 without), and all patients were randomly assigned to a training (n = 86) and a validation (n = 36) cohort. Radiomic features were extracted from pre-treatment CTs, clinically predictors were identified by logistic regression analysis. Lasso regression model was used for feature selection, and radiomics signature building. Multivariable logistic regression analysis was used to develop the clinical nomogram, radiomics-clinical nomogram and radiomics prediction model. The models were validated and compared by discrimination, calibration, reclassification, and clinical benefit. RESULTS: The radiomic signature consisting of ten selected features, was significantly associated with esophageal fistula (P = 0.001). Radiomics-clinical nomogram was created by two predictors including radiomics signature and stenosis, which was identified by logistic regression analysis. The model showed good discrimination with an AUC = 0.782 (95% CI 0.684-0.8796) in the training set and 0.867 (95% CI 0.7461-0.987) in the validation set, with an AIC = 101.1, and good calibration. When compared to the clinical prediction model, the radiomics-clinical nomogram improved NRI by 0.236 (95% CI 0.153, 0.614) and IDI by 0.125 (95% CI 0.040, 0.210), P = 0.004. CONCLUSION: We developed and validated the first radiomics-clinical nomogram for malignant esophageal fistula, which could assist clinicians in identifying patients at high risk of MEF.

[Double aortic arch and aortotracheal fistula as cause of fatal massive bleeding: a rare and dangerous association]. / Doble arco aórtico y fistula aortotraqueal como causa de hemorragia masiva fatal: una asociación rara y peligrosa.

Vascular rings are unusual congenital malformations. Among them, double aortic arch (DAA) is often difficult to diagnose due to its low incidence of symptoms. DAA can be associated with tracheal or esophageal compression and, in severe cases, could require tracheal intubation or chronic use of a nasogastric tube. This scenario favors the development of aortotracheal fistulas (ATF) or aortoe-sophageal fistulas (AEF). OBJECTIVE: To present a clinical case with an unusual association of DAA with ATF and to reinforce the importance of maintaining high diagnostic suspicion in patients with massive aerodigestive bleeding without an obvious source. CLINICAL CASE: A 32-week preterm newborn who required prolonged mechanical ventilation and presented intermittent episodes of massive oropharyngeal bleeding with hemodynamic compromise associated with lower airway obstruction without pulmonary hemorrhage. The patient underwent upper endoscopy and exploratory laparotomy without evidence of bleeding. Flexible nasopharyngolaryngoscopy and direct laryngoscopy also showed no abnormalities. A CT angiography showed complete DAA with indentation of the left dominant arch over the trachea, without severe stenosis or evidence of a fistula. AEF was suspected, so exploratory surgery was considered. However, the patient died before surgery due to a massive pulmonary hemorrhage. The autopsy revealed the presence of ATF. CONCLUSIONS: In patients with massive aerodigestive bleeding without an obvious source, the presence of DAA and possible AEF/ ATF should be considered. Imaging studies have a poor performance for this diagnosis, so surgery should be considered for diagnosis and treatment in these patients.

Vascular covered stent and video-assisted thoracoscopic surgery for Aortoesophageal fistula caused by esophageal fishbone: a case report.

BACKGROUND: Aortoesophageal fistula (AEF) is a rare condition characterized by communication between the aorta and esophagus. AEF caused by an esophageal foreign body is even rare, and there is currently no recommended standard treatment protocol. We report a case of delayed aortic rupture after the endoscopic removal of a fish bone, which was successfully treated with a combined approach of vascular stenting and thoracic surgery. CASE PRESENTATION: A 33-year-old man presented to the hospital after experiencing chest discomfort for 3 days following the accidental ingestion of a fish bone. Under endoscopic guidance, the fish bone was successfully removed, and the patient was subsequently admitted for medical therapy. On the fourth postoperative day, the patient suddenly developed hematemesis, and chest computed tomography angiography revealed the presence of an AEF. This necessitated urgent intervention; hence, thoracic surgery was performed and a vascular-covered stent was placed. Following the surgical procedure, the patient received active medical treatment, recovered well, and was successfully discharged from the hospital. CONCLUSIONS: In patients with esophageal perforation caused by foreign bodies, hospitalization for observation, computed tomography angiography examination, early use of antibiotics, and careful assessment of aortic damage are advised. Thoracic endovascular aortic repair and esophageal rupture repair may have benefits for the treatment of AEF.

Clinical responses to vemurafenib in postoperative recurrence of papillary thyroid carcinoma with esophageal fistula: A case report.

BACKGROUND: While papillary thyroid carcinoma (PTC) generally exhibits a favorable prognosis post-surgery, the poorly differentiated subtype presents elevated rates of postoperative recurrence. Certain aggressive cases demonstrate invasive behavior, compromising adjacent structures and leading to a poor prognosis. This study delineates a unique case of postoperative PTC recurrence, complicated by esophageal fistula, that showed favorable outcomes following brief Vemurafenib treatment. PATIENT DESCRIPTION: A 64-year-old female patient underwent surgical resection for PTC, subsequently experiencing rapid tumor recurrence and development of an esophageal fistula. DIAGNOSIS: The patient was confirmed to have locally advanced PTC through intraoperative cytopathology. The cancer recurred postoperatively, culminating in the formation of an esophageal fistula. METHODS: The patient was administered Vemurafenib at a dosage of 960 mg twice daily following tumor recurrence. RESULTS: A 12-month regimen of targeted Vemurafenib therapy led to a substantial reduction in tumor size. Concurrently, the esophageal fistula underwent complete healing, facilitating successful removal of the gastrostomy tube. The tumor response was classified as stable disease. CONCLUSION SUBSECTIONS: Vemurafenib demonstrates potential as a targeted therapeutic strategy for recurrent PTC harboring the BRAFV600E mutation. This approach may effectively mitigate tumor dimensions and the associated risk of esophageal and tracheal fistulas.

Efficacy of thoracic endovascular aortic repair for aorto-esophageal fistula due to esophageal cancer: a systematic review and meta-analysis.

Aorto-esophageal fistula (AEF) due to esophageal cancer (EC) is a life-threatening condition characterized by sudden hemorrhage, which often causes sudden death. To evaluate the efficacy and safety of thoracic endovascular aortic repair (TEVAR) for AEF due to EC, we performed a systematic review and meta-analysis. We searched the MEDLINE (PubMed) databases, the Cochrane Library databases, Ichushi-Web (the databases of the Japan Medical Abstract Society), and CiNii (Academic information search service of the National Institute of Information from Japan) from January 2000 to November 2023 for articles about TEVAR for an emergent aortic hemorrhage (salvage TEVAR [S-TEVAR]), and the prophylactic procedure (P-TEVAR). Six studies (140 cases) were eligible for meta-analysis. The 90-day mortality of S-TEVAR and P-TEVAR was 40% (95% CI 23-60, I2 = 36%) and 8% (95% CI 3-17, I2 = 0%), respectively. Post-S-TEVAR hemorrhagic and infectious complications were 17% (95% CI 3-57, I2 = 71%) and 20% (95% CI 5-57, I2 = 66%), respectively. Post-P-TEVAR hemorrhagic and infectious complications were 2% (95% CI 0-10, I2 = 0%) and 3% (95% CI 1-12, I2 = 0%), respectively. TEVAR for AEF due to EC may be a useful therapeutic option to manage or prevent hemorrhagic oncological emergencies.

Efficacy of airway stenting and nasogastric tube insertion in airway-esophageal fistula patients with airways compromised by advanced malignancy.

INTRODUCTION: Whether airway-compromised airway-esophageal fistula (AEF) patients should undergo combined airway and esophageal stenting is controversial. This study was designed to evaluate the survival prognosis and poststent interventions in AEF patients with airways compromised by advanced malignancy with or without airway stents. METHODS: A retrospective analysis of the medical records, survival times, and poststent interventions of 17 patients with or without airway stents was performed. RESULTS: The causes of AEF were esophageal cancer (11/17, 64.7%), lung cancer (6/17, 29.4%), and thyroid cancer (1/17, 5.9%). All patients received a nasogastric tube (n = 12) or underwent gastrostomy (n = 5) to resume enteral nutrition. Thirteen patients underwent airway stent insertion (13/17, 76.5%), whereas four patients did not. Four patients with a high risk of stent migration received external stent fixation to the trachea. Three of the patients with stents suffered severe granulation tissue formation and needed repeated bronchoscopy interventions. In the stented group, none of the patients developed stent migration, and the overall median survival time was 9 months, compared with 1.25 months in the nonstented group (P = 0.04). Cox proportional hazards regression revealed that stent insertion, nasogastric tube insertion, and transcatheter bronchial artery chemoembolization were protective factors against death, whereas surgery-related fistula, fistula larger than 2 cm, continued chemotherapy, and age were risk factors for poor survival (P < 0.05). CONCLUSION: In airway-compromised AEF patients, airway stents and nasogastric tubes are probably the preferred treatments. Airway stenting is tolerable, and routine weekly poststent bronchoscopy is needed in the first month and depending on respiratory symptoms thereafter.