Clinical outcomes of radiation therapy for clinical T4b oesophageal cancer with airway invasion.

BACKGROUND: Oesophageal cancer with airway invasion presents a challenge for therapy and often has serious complications. We analysed the clinical outcomes of radiation therapy (RT) in patients with clinical T4b oesophageal cancer with airway invasion. METHODS: We retrospectively reviewed the medical records of 73 patients with oesophageal cancer who had clinical T4 disease and who received RT between January 1994 and June 2017. Among them, 47 patients with clinical T4b disease with airway invasion were included in this study; 31 had gross invasion on bronchoscopy and 16 had extrinsic compression with mucosal change. We investigated the survival outcomes, clinical courses, and toxicities. RESULTS: The median survival (MS) time was 9 months. The 1- and 2-year overall survival (OS) rates were 41.4 and 27.4%, respectively. The MS times for patients treated with curative or palliative aims were 15 and 4 months, respectively (p = 0.001). Seven patients (14.9%) had fistulae at diagnosis; after RT, three had no change in size, three closed, and one had increased. Newly developed oesophageal fistulae after treatment were observed in 13 patients (27.7%). The median time to a newly developed fistula was 3 months (range, 1-15). Among them, a fistula was closed in only one patient. Death from aspiration pneumonia occurred in one patient who had a fistula at diagnosis and in nine patients who newly developed fistulae after treatment. Severe oesophageal bleeding causing death occurred in two patients. Patients with gross invasion on bronchoscopy had a higher risk of developing a fistula than did patients with mucosal change (37.5% vs. 25.0%, respectively). CONCLUSIONS: Even for clinical T4b disease with airway invasion, RT with a curative aim showed acceptable survival outcomes in patients with good performance status and no distant metastasis at initial diagnosis. However, the risk of fistula development associated with fatal events remains high. Further study is warranted to decrease the risks of treatment and improve clinical outcomes. TRIAL REGISTRATION: Retrospectively registered.

Safety and efficacy of the nMARQ catheter for paroxysmal and persistent atrial fibrillation.

AIMS: Circular irrigated radiofrequency ablation using the nMARQ catheter has recently been introduced for the treatment of atrial fibrillation (AF). The aim of this study is to report the safety and efficacy of catheter ablation using this technology in patients with paroxysmal and persistent AF. METHODS AND RESULTS: The data of a prospective registry describing the experience of a single operator using this technology on 327 consecutive patients were analysed. The mean procedure time was 69 ± 22 min for paroxysmal AF (n = 228) and 75 ± 23 min for persistent AF (n = 97). Follow-up was available for 206 (63%) patients for 6 ± 5 months (range 1-23, median 3.3). Single procedure success off antiarrhythmic drugs was 75% in paroxysmal AF and 52% in persistent AF. Including the 5% redo cases and those on antiarrhythmic medication, freedom from AF was documented in 90 and 83% of paroxysmal and persistent AF patients, respectively. There were no serious complications in the first 325 patients, but the last two consecutive patients (0.6%) developed atrio-oesophageal fistulas and had a fatal outcome. The catheter has been recalled from market. CONCLUSION: The nMARQ catheter is a highly effective tool for treatment of paroxysmal and persistent AF. Nevertheless, the occurrence of life-threatening oesophageal fistulas is of major concern and requires further investigation.

Atrioesophageal fistula in the era of atrial fibrillation ablation: a review.

The purpose of this review is to understand the epidemiology, clinical features, etiopathogenesis, and management of atrioesophageal fistula (AEF) after atrial fibrillation (AF) ablation. The incidence of AEF after AF ablation is 0.015%-0.04%. The principal clinical features include fever, dysphagia, upper gastrointestinal bleeding, sepsis, and embolic strokes. The close proximity of the esophagus to the posterior left atrial wall is responsible for esophageal injury during ablation. Prophylactic proton pump inhibitors, esophageal temperature monitoring, visualization of the esophagus during catheter ablation, esophageal protection devices, and avoidance of energy delivery in close proximity to the esophagus play an important role in preventing esophageal injury. Early surgical repair or esophageal stenting are the mainstay of treatment. Eliminating esophageal injury during AF ablation is of utmost importance in preventing AEF. A high index of suspicion and early intervention is necessary to prevent fatal outcomes.

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.

Successful thoracic endovascular aortic repair of an aortoesophageal fistula.

We report three cases of aortoesophageal fistula (AEF), in which the patients remained free from catastrophic bleeding after endovascular stent-grafting. The three patients, who were not candidates for surgical repair because of their poor general condition and prognosis, underwent endovascular stent-grafting following the administration of antibiotics and were successfully managed; hemostasis was maintained for several months until their death. Although we did not find any conclusive evidence to support this strategy, our experiences suggest that endovascular stent-grafting of AEF is useful for maintaining hemodynamic stability.

Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux-limb placement.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an increasingly popular bariatric procedure. However, after LSG, leaks may occur that are difficult to treat and that can persist for months. Treatment is controversial and ranges from stent placement to total gastrectomy. We propose an alternative laparoscopic treatment. The aims of our study were to report on the incidence of chronic fistulas after LSG and the outcome of Roux-limb placement on these defects. The setting was a major teaching hospital in Belgium. METHODS: From January 1, 2002, to December 31, 2011, we performed LSG as a primary weight loss operation (PLSG) in 728 patients and as a corrective operation (CLSG) in 84 patients. A retrospective chart and database review was conducted. When a chronic leak persisted beyond 4 months, we performed a laparoscopic Roux-limb placement on the defect. RESULTS: Leaks occurred in 26 patients (3.6%) after PLSG and in 6 (7.1%) after CLSG. A leak persisted beyond 4 months in 7 patients (26.9%) after PLSG and in 2 patients (33.3%) after CLSG. Two patients with a chronic fistula after PLSG were referred to our hospital. In 11 patients, a Roux limb was laparoscopically sutured to the defect. The mean time for a chronic fistula to heal after Roux-limb placement was 12.5±10.2 days, and the mean length of hospital stay was 19.6± 14.2. CONCLUSION: Proximal leaks after LSG are relatively rare. However, a significant number become chronic. Laparoscopic placement of a Roux-limb on the defect is a safe treatment with an eventual succes rate of 100%.

Prophylactic proton pump inhibition after atrial fibrillation ablation: is there any evidence?

The development of an atrio-oesophageal fistula following catheter ablation for atrial fibrillation is a well known, but rare complication with a high mortality, partially due to the late fistula formation weeks after the initial procedure. Technical measurements are undertaken to avoid oesophageal damage during catheter ablation of atrial fibrillation, yet, oesophageal and mediastinal lesions occur in a substantial number of patients following pulmonary vein isolation. This has led to prophylactic use of proton pump inhibitors in many centres. Current guidelines and consensus reports list no objectives on this issue. The aim of the paper is therefore to review current clinical and experimental evidence for this treatment.

[A CASE OF ESOPHAGOGASTRIC FISTULA CURE IN A PATIENT WITH COMPLICATED TUBERCULOSIS OF INTRATHORACIC LYMPH NODES].

The authors describe a successful case of esophageal fistula being cured in a patient with complicated tuberculosis of intrathoracic lymph nodes. They show it possible to medically cure the fistula via temporary esophageal stenting, which in combination with therapeutic bronchoscopies enables prompt fistula healing, without resorting to surgical treatment.

Oesophageal perforation after anterior cervical surgery: management in four patients.

BACKGROUND: Oesophageal perforation related to anterior cervical surgery is an uncommon but well recognised and potentially life-threatening complication with an incidence of 0-3.4%. Our experience with this complication and a review of the literature are presented. METHOD: We retrospectively reviewed our clinical experience over 10 years and found four patients in whom an oesophageal perforation was recognised after anterior surgery for cervical spine trauma. In three patients the perforation was noticed in the early post-operative period and the other had a delayed presentation. In all patients, the hardware was removed, long-term intravenous antibiotics were administered and parenteral nutrition was instituted. In two patients a primary suture of the perforation was performed and in one of these an additional sternocleidomastoid myoplasty was carried out as well. One patient had conservative treatment and one died before closure of the perforation could be performed. FINDINGS: The two patients, in whom surgical repair of the perforation was performed, recovered well with residual neurological deficits as expected due to the cervical trauma. In the patient in whom conservative treatment was instituted, healing of the perforation occurred. One patient died due to systemic complications, indirectly related to the perforation. CONCLUSIONS: Although not very frequent and sometimes difficult to diagnose, oesophageal perforations after anterior cervical surgery constitute a potentially life-threatening complication. Diagnosis is made by imaging or endoscopic studies, but clinical suspicion is most important. Basic treatment consists of surgery with removal of hardware, drainage of abscesses, primary closure of the perforation if possible, parenteral nutrition and antibiotic therapy. Residual instability should be recognised in time and may be anticipated in patients in whom there has been little time for solid bony fusion. Successful management depends on early diagnosis and immediate institution of treatment.

[Congenital bronchoesophageal fistula in an adult; an undiscribed mechanism of symptom tolerance].

We present a case of a congenital bronchoesophageal fistula in a 61-year-old woman. She was referred to hospital because of postprandial heart burn. Three-dimensional (3D) computed tomography (CT) demonstrated an anastomosis between her right intermediate bronchus and esophagus. In spite of direct communication between her bronchus and esophagus, she has never suffered severe infection. We visualized the orifice of fistula closed with mucosal flap in swallowing by means of a bronchofiberscope. The delay of a diagnosis was explained by symptom tolerance. Some theories as to the symptom tolerance are found in literatures, but we supposed to find an undiscribed mechanism; closure of the orifice in swallowing. The fistula was surgically closed.

Beware the starboard nasogastric tube.

A mycotic pseudoaneurysm of the thoracic aorta is a rare entity in the pediatric population. It carries a high mortality rate associated with spontaneous rupture. Aortoesophageal fistula is a known complication of a pseudoaneurysm but is also rare in this group. A high index of suspicion is needed to make the diagnosis. This is aided by radiograph and computed tomography. We present such a case in an 11-year-old boy with previously undiagnosed coarctation of the aorta.

Stacked proximal aortic cuffs: an "off-the-shelf" solution for treating focal thoracic aortic pathology.

PURPOSE: To report our early experience with the endovascular placement of stacked Zenith main body extensions (cuffs) in the treatment of focal thoracic aortic pathology in high-risk patients. METHODS: Between January 2003 and May 2004, 6 patients (3 men; mean age 59 years, range 37-82) with focal aortic pathology underwent endovascular repair using stacked 30 and 32-mm-diameter Zenith main body extensions. The setting was a university tertiary referral center for vascular disease. Indication for treatment included 2 descending thoracic aneurysms and individual cases of traumatic thoracic tear, diverticulum of Kommerell, thoracic pseudoaneurysm, and aortoesophageal fistula. RESULTS: All procedures were performed successfully, with a mean of 3 cuffs used. The patient with an aortoesophageal fistula expired after successful cuff placement due to sequela of massive pretreatment hemorrhage; fistula coverage was confirmed at autopsy. There were no type I endoleaks. Morbidity included an occluded right subclavian artery from traumatic passage of the device through the artery. No left subclavian arteries were covered. No neurological deficits or paraplegia was observed. The cuffs were patent in all surviving patients at an average follow-up of 7 months (range 3-12). Computed tomography in all survivors confirmed adequate cuff placement, absence of endoleak, and lack of cuff migration. Based on this experience, the following technical recommendations are offered: (1) right subclavian cutdown when needed to reach a lesion beyond the range of the sheath, (2) Dacron chimney placement, (3) stiff guidewire usage, (4) wire placement from the right subclavian artery through the common femoral artery if necessary to ease a sharp bend in the arch, and (5) cuff overlap of 25% to 50%. CONCLUSIONS: In high-risk patients, focal aortic pathology can be successfully treated with off-the-shelf commercially available cuffs using a stacking technique with acceptable mortality, morbidity, and short-term durability.

Are self-expanding metal mesh stents useful in the treatment of benign esophageal stenoses and fistulas? An experience of four cases.

OBJECTIVE: The aim of this study was to review the long-term results of treating benign esophageal fistula and stenosis using self-expanding metal stents. METHODS: We treated four patients using covered mesh or coiled stents. We removed the stents electively in two patients (one endoscopically and one during planned partial esophagectomy) and unexpectedly in one patient who developed bleeding. One stent migrated and required laparotomy for removal. RESULTS: Placement of self-expanding metal stents successfully sealed the benign fistula in two patients and reestablished swallowing in two other patients with complicated achalasia. Two patients were swallowing normally on long-term follow-up, one died of the underlying disease, and one required gastrostomy. CONCLUSION: Temporary use of self-expanding metal stents as a feasible option for treating benign esophageal stenosis and fistula in patients who have failed other conventional treatments.

Fístula aortoesofágica por cuerpo extraño con supervivencia postoperatoria y desenlace final fatal / Fatal outcome of surgery for aortoesophageal fistula secondary to foreign body despite postoperative survival

La fístula aortoesofágica es una entidad de muy baja frecuencia, de consecuencias fatales en la mayor parte de las ocasiones. Como causas de la misma encontramos que la más frecuente resulta ser la rotura de un aneurisma aórtico, tras la cual se halla la impactación de un cuerpo extraño en el esófago. Al ser la supervivencia de estos enfermos ínfima, surgen ciertos aspectos que pueden ser tenidos en cuenta a la hora de aumentar aquélla, como el reconocimiento precoz y control de la hemorragia y la rápida intervención quirúrgica utilizando un refuerzo del cierre aórtico mediante un tejido adecuadamente vascularizado (AU)

General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances.

Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.