Atrioesophageal Fistula Following Radiofrequency Catheter Ablation of Atrial Fibrillation.

Atrioesophageal fistula (AEF) is a rare but catastrophic complication of catheter ablation of atrial fibrillation (AF), with an incidence of 0.03% to 1.5% per year. We report two cases and review the epidemiology, clinical features, pathogenesis, and management of AEF after AF ablation. The principal clinical features of AEF include fever, hematemesis, and neurologic deficits within 2 months after ablation. The close proximity of the esophagus to the posterior left atrial wall is considered responsible for esophageal injury during ablation and the eventual development of AEF. Prophylactic proton pump inhibitors, esophageal temperature monitoring, visualization of the esophagus during catheter ablation, esophageal protection devices, esophageal cooling, and avoidance of energy delivery in close proximity to the esophagus are some techniques to prevent esophageal injury. Eliminating esophageal injury during AF ablation is of utmost importance in preventing AEF. A high index of suspicion and early intervention are necessary to prevent fatal outcomes. Early surgical repair is the mainstay of treatment.

Contact-Force Catheters: Efficacy Versus Safety? Case Report of 2 Atrioesophageal Fistulae.

Contact-force (CF) catheters appear to be more effective compared to standard ablation catheters for complex radiofrequency ablation including atrial fibrillation (AF) ablation when optimal CF >10 g is achieved. Some have suggested that this technology could also improve procedural safety. We report 2 cases of atrioesophageal fistulae (AEF), a rare but catastrophic complication of AF ablation. These are to our knowledge the first cases of AEF described after using CF catheters.

Risk Factors for Esophageal Fistula Associated With Chemoradiotherapy for Locally Advanced Unresectable Esophageal Cancer: A Supplementary Analysis of JCOG0303.

Esophageal fistula is a critical adverse event in patients treated with chemoradiotherapy (CRT) for locally advanced esophageal cancer. However, risk factors associated with esophageal fistula formation in patients receiving CRT have not yet been elucidated.We retrospectively analyzed data obtained from 140 patients who were enrolled in a phase II/III trial comparing low-dose cisplatin with standard-dose cisplatin administered in combination with 5-flurouracil and concomitant radiotherapy. Inclusion criteria were performance status (PS) 0 to 2 and histologically proven thoracic esophageal cancer clinically diagnosed as T4 and/or unresectable lymph node metastasis for which definitive CRT was applicable. Risk factors for esophageal fistula were examined with univariate analysis using Fisher exact test and multivariate analysis using logistic regression models.Esophageal fistula was observed in 31 patients (22%). Of these, 6 patients developed fistula during CRT. Median time interval between the date of CRT initiation and that of fistula diagnosis was 100 days (inter quartile range, 45-171). Esophageal stenosis was the only significant risk factor for esophageal fistula formation both in univariate (P = 0.026) and in multivariate analyses (odds ratio, 2.59; 95% confidence interval, 1.13-5.92, P = 0.025). Other clinicopathological factors, namely treatment arm, age, sex, PS, primary tumor location, T stage, lymph node invasion to adjacent organs, blood cell count, albumin level, and body mass index, were not risk factors fistula formation.Esophageal stenosis was a significant risk factor for esophageal fistula formation in patients treated with CRT for unresectable locally advanced thoracic esophageal squamous cell carcinoma.

Esophageal-subarachnoid fistula: a case of spontaneous tension pneumocephalus in the setting of esophageal cancer.

BACKGROUND: Pneumocephalus occurs as a result of traumatic or iatrogenic violation of the dura. Tension pneumocephalus, whereby air continues to accumulate with no mechanism for escape, can cause significant morbidity and mortality. METHODS: This case report reviews the underlying pathophysiology, clinical presentation, diagnosis, and management of tension pneumocephalus. RESULTS: We present the case of a 68-year-old man who presented to the Emergency Department with headache thought to be the result of a newfound intracranial mass. After admission, he became obtunded and was found to have tension pneumocephalus requiring emergent evacuation. A cervical esophagus carcinoma caused an esophageal-subarachnoid fistula that resulted in tension pneumocephalus after a retching episode. CONCLUSION: This case illustrates the importance of considering alternative sources of pneumocephalus in the absence of more typical differential diagnosis.

Atrioesophageal fistula after cryoballoon pulmonary vein isolation.

The risk of atrioesophageal fistula after cryoballoon pulmonary vein isolation is thought to be much lower than after radiofrequency ablation, seeing that no data exist on this complication so far. We report for the first time on the occurrence of an atrioesophageal fistula 4 weeks after cryoballoon ablation at the site of the left inferior pulmonary vein. We suggest that even when using cryothermal ablation technique, an imaging modality to assess the proximity of esophagus and left atrium should be routinely performed to avoid this fatal complication.

Successful enteral nutrition in the treatment of esophagojejunal fistula after total gastrectomy in gastric cancer patients.

BACKGROUND: Esophagojejunal fistula is a serious complication after total gastrectomy in gastric cancer patients. This study describes the successful conservative management in 3 gastric cancer patients with esophagojejunal fistula after total gastrectomy using total enteral nutrition. METHODS: Between January 2004 to December 2008, 588 consecutive patients with a proven diagnosis of gastric cancer were taken to the operation room to try a curative treatment. Of these, 173 underwent total gastrectomy, 9 of them had esophagojejunal fistula (5.2%). In three selected patients a trans-anastomotic naso-enteral feeding tube was placed under fluoroscopic vision when the fistula was clinically detected and a complete polymeric enteral formula was used. RESULTS: The complete closing of the esophagojejunal fistula was obtained in day 8, 14 and 25 respectively. CONCLUSION: In some selected cases it is possible to make a successful enteral nutrition using a feeding tube distal to the leak area inserted with the help of fluoroscopic vision. The specialized management of a gastric surgery unit and nutritional therapy unit are highlighted.

Pneumopericardium following radiofrequency ablation for atrial fibrillation: insights into the natural history of atrial esophageal fistula formation.

We present a case of large pneumopericardium resulting from an esophageal pericardial fistula following ablation for atrial fibrillation (AF). The presentation, evaluation, and management of this specific patient, along with a review of present techniques to diagnose esophageal injury, provide a unique insight into the pathophysiology of left atrial-esophageal fistula formation.

Percutaneous catheter ablation of atrial fibrillation.

Atrial fibrillation is the most common arrhythmia and is associated with important morbidity and mortality. Antiarrhythmic therapy is recommended as initial therapy but is associated with modest efficacy and significant side effects. Over the past several years, catheter ablation has been demonstrated to provide effective and safe curative therapy for atrial fibrillation. Future investigations will assess advances in catheter ablation technology and will help to define the precise role of catheter ablation relative to alternative therapies, such as rate-control and antiarrhythmic therapy.

A phase I/II study of external beam radiation, brachytherapy, and concurrent chemotherapy for patients with localized carcinoma of the esophagus (Radiation Therapy Oncology Group Study 9207): final report.

BACKGROUND: A multiinstitutional, prospective study of the Radiation Therapy Oncology Group (RTOG) was designed to determine the feasibility and toxicity of chemotherapy, external beam radiation, and esophageal brachytherapy (EB) in a potentially curable group of patients with adenocarcinoma or squamous cell carcinoma of the esophagus. A preliminary analysis indicated a 17% 1-year actuarial risk of treatment-related fistulas. A final analysis of this study was considered important to determine the median survival time, local control, and late toxicity associated with this treatment regimen. METHODS: Planned treatment was 50 grays (Gy) of external beam radiation (25 fractions given over 5 weeks) followed 2 weeks later by EB (either high-dose-rate 5 Gy during Weeks 8, 9, and 10, for a total of 15 Gy, or low-dose-rate 20 Gy during Week 8). Chemotherapy was given during Weeks 1, 5, 8, and 11, with cisplatin 75 mg/m(2) and 5-fluorouracil 1000 mg/m(2)/24 hours in a 96-hour infusion. RESULTS: Of the 49 eligible patients, 45 (92%) had squamous histology and 4 (6%) had adenocarcinoma. Forty-seven patients (96%) completed external beam radiation plus at least 2 courses of chemotherapy, whereas 34 patients (69%) were able to complete external beam radiation, EB, and at least 2 courses of chemotherapy. The estimated survival rate at 12 months was 49%, with an estimated median survival of 11 months. Life-threatening toxicity or treatment-related death occurred in 12 (24%) and 5 (10%) cases, respectively. Treatment-related esophageal fistulas occurred in 6 cases (12% overall, 14% of patients starting EB) at 0.5-6.2 months from the first day of brachytherapy, leading to death in 3 cases. CONCLUSIONS: In this study, severe toxicity, including treatment-related fistulas, occurred within 7 months of brachytherapy. Based on the 12% incidence of fistulas, the authors continue to urge caution in employing EB, particularly when used in conjunction with chemotherapy.

A phase I/II study of external beam radiation, brachytherapy and concurrent chemotherapy in localized cancer of the esophagus (RTOG 92-07): preliminary toxicity report.

PURPOSE: A multi-institutional, prospective study was designed to determine the feasibility and tolerance of external beam irradiation plus concurrent chemotherapy and esophageal brachytherapy (EB) in a potentially curable group of patients with adenocarcinoma or squamous cell carcinoma of the esophagus. METHODS AND MATERIALS: Planned treatment was 50 Gy external beam radiation (25 fractions/5 weeks) followed 2 weeks later by EB [either high dose rate (HDR) 5 Gy, weeks 8, 9, and 10, for a total of 15 Gy, or low dose rate (LDR) 20 Gy, week 8]. The protocol was later revised to delete the LDR alternative, owing to poor accrual, and to decrease the HDR dose to 10 Gy (i.e. 5 Gy, weeks 8 and 9). Chemotherapy was given weeks 1, 5, 8, and 11 with cisplatin 75 mg/m2 and 5-fluorouracil 1000 mg2/m per 24 h, 96-h infusion. The study closed in January 1995 after 56 patients had been entered on the HDR arm. Six patients were declared ineligible owing to tumor extension to the gastroesophageal junction (three patients) or involved celiac lymph nodes (three patients). Of the 50 eligible patients, the planned EB dose was 15 and 10 Gy in 40 and 10 patients, respectively. Forty-six (92%) of the eligible patients had squamous histology, and three (6%) adenocarcinoma. RESULTS: Life-threatening toxicity or treatment-related death occurred in 13 (26%) and 4 (8%) of the 50 eligible patients, respectively. Treatment-related esophageal fistulas occurred in three patients (12% overall, 14% of patients starting EB) at 0.5-6.2 months from the first day of brachytherapy, leading to death in three. The fourth death was secondary to renal toxicity and infection attributed to chemotherapy. No correlation was found between the development of fistula and location of primary tumor, brachytherapy active length or applicator diameter. So far, 5 of the 6 treatment-related fistulas have occurred following 15 Gy EB. The other fistula occurred after only 5 Gy of a planned 15 Gy was delivered. CONCLUSION: Thirty-five patients (70%) were able to complete external beam, EB, and at least two courses of chemotherapy. Estimated survival rate at 12 months is 48%, with an estimated 11-month median survival rate. Survival following external beam radiation plus concurrent chemotherapy and EB does not appear to be significantly different from survival seen following external beam radiation and chemotherapy only. The development of six fistulas in the 35 patients completing EB is of concern. Based on the high incidence of fistulas, we urge extreme caution in employing EB as a boost following concurrent external beam radiation and chemotherapy.

[Esophago-bronchial fistula in adults]. / Les fistules oeso-bronchiques de l'adulte.

The authors report five cases of benign oesophago-bronchial fistula in adults. These chronic bronchitic patients presented with recurrent episodes of secondary lung infections (or even haemoptysis). Questioning of the patients revealed a history of coughing when swallowing liquids in three cases. Two women concealed this symptom, which was only revealed retrospectively. The fistula was detected by upper GI series in three cases and by oesophageal fibroscopy in one case. In the remaining case, it was discovered at operating for severe haemoptysis. In four of the five cases, the fistula was situated on the right and was of post-tuberculous origin. In one case of post-traumatic fistula, it involved the left main bronchus. All of the patients were operated: a resection-suture of the fistula was performed via the oesophageal approach and, via the bronchial approach, simple suture of the fistula was possible in two cases, while resection of the destroyed pulmonary parenchyma was necessary in three cases (one right lower lobectomy, two bilobectomies). Demonstration of the oesophago-bronchial fistula, definition of its site and assessment of the condition of the pulmonary parenchyma are essential steps to be performed prior to surgery.