First Result of a Tailored Progressive Multistep Approach for the Treatment of Aorto-esophageal Fistulae.

BACKGROUND: Aorto-esophageal fistulae (AEFs) are a rare but serious and life-threatening disease of the mediastinum. Especially, AEF in the presence of infected stent grafts, for example, after thoracic endovascular aortic repair (TEVAR) is only curable by a multistage interdisciplinary surgical approach. This study presents the results of our four-stage approach consisting of bridging TEVAR, esophagectomy, complete stent removal followed by total bovine tube aortic replacement (TBTAR), and finally esophageal reconstruction. METHODS: A case series of four patients from our department receiving a four-stage treatment of AEF is presented in this study. Retrospective database analysis focusing on overall survival, duration of intensive care unit and total hospital stay until discharge, complications, surgical time frame, and completion of chosen surgical treatment course was performed. RESULTS: Overall, four patients surgically treated for AEF since May 2015 were included. A 30-day mortality was 0%, and overall survival at 1 year was 75%. All patients survived more than 5 months and could be discharged after TEVAR and esophagectomy. TBTAR could be performed in two of four patients (50%). Esophageal reconstruction was completed in all patients. Average follow-up was 20.3 ± 1.7 months or until death. CONCLUSION: The acute management of AEF using this approach seems satisfactory, especially for reducing acute short-term mortality. Complete restoration of the circulatory system and digestive tract remains challenging and is associated with high morbidity. We support the application of bridging TEVAR with a staggered approach to further surgical treatment individually tailored to the patient.

Management of Tumor- and Nontumor-related Aorto-esophageal and Aorto-bronchial Fistulas.

BACKGROUND: This study aims to review and compare the clinical presentation, management, and outcome in patients with tumor-related (TR) and nontumor-related (NTR) aorto-esophageal fistula (AEF) and aorto-bronchial fistula (ABF) with particular focus on the thoracic endovascular aortic repair. METHODS: We retrospectively reviewed a series of 16 consecutive patients with TR (n = 8) and NTR (n = 8), ABF (n = 6), and AEF (n = 10) admitted to our hospital from 2011 to 2019. RESULTS: The median age was 62 years (range 46-81), with 11 men. The most common predisposing factor was esophageal or gastric cardia cancer (n = 6), followed by open repair of the thoracic aorta (n = 5). Endoluminal vacuum therapy (Endo-SPONGE®) accounted for 3 cases of AEFs. Thoracic endovascular aortic repair (TEVAR) was applied in 13 patients (4 with ABFs and 9 with AEFs). The primary technical success of the TEVARs was 100%. One patient (8%) was complicated with postoperative middle cerebral artery syndrome and left-sided hemiparesis. The respective in-hospital, 6-month, and 1-year mortality rates were 0% (n = 0), 25% (n = 2), and 25% (n = 2) for the NTR group and 63% (n = 5), 88% (n = 7), and 100% (n = 8) for the TR group. After a mean period of 13 months, 5 (31%) patients were still alive, and one patient lost to follow-up after 11 months. The survivors (n = 5) had all nontumor-related ABF. Progression of underlying cancer and hemodynamic shock were the most common causes of death. CONCLUSIONS: TEVAR represents a reliable option in the treatment of NTR ABFs. In the cases of TR fistulas and NTR AEFs, TEVAR should be applied more selectively. The associated mortality remains very high.

Aorto-esophageal fistula - An autopsy series.

BACKGROUND: Fistulous tracts within the thorax are best exemplified aorto-esophageal fistulas (AEFs), which are rare exsanguinations of the upper gastrointestinal tract. Most of them are diagnosed at autopsy. AIM: This is an autopsy-based study of fatal cases of AEFs gathered over a period of 20 years. MATERIALS AND METHODS: Cases of AEFs were retrieved from the autopsy records of the cardiovascular pathology sub-specialty at a tertiary care center and were studied with reference to demographic details, modes of clinical presentation, and pathological features. RESULTS: Ten cases of AEFs (10 males and 8 females, mean age of 46.9 years) were identified in a span of 20 years. A clinical diagnosis of AEF was made in only one patient, while the rest were identified at autopsy. All the patients had a bout of massive and fatal hematemesis. The fistulous connections, involving the middle-third of the esophagus, were caused by a fishbone, esophageal ulceration and aneurismal aortic diseases of varied etiology. CONCLUSIONS: AEFs are often missed or misdiagnosed. Early recognition of this rapidly fatal condition is essential as these fistulas require quick and aggressive management.

Survival and prognostic factors of patients with esophageal fistula in advanced esophageal squamous cell carcinoma.

The aim of the present study was to investigate the survival and prognostic factors of patients who were with advanced esophageal squamous cell carcinoma (ESCC) and developed an esophageal fistula. The data from 221 patients with advanced ESCC developed esophageal fistula from January 2008 to December 2017 at the Harbin Medical University Cancer Hospital was retrospectively analyzed. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by the Cox proportional hazard models. The median survival time after a diagnosis of the esophageal fistula was calculated using the Kaplan-Meier method. We found that the pathogens infected by patients are common bacteria in nosocomial infection. Besides, the incidence rate of esophagomediastinal fistula was the highest (54.2%) in the lower third of the esophagus. Kaplan-Meier analysis revealed a median survival time of 11.00 months and a median post-fistula survival time of 3.63 months in patients who developed esophageal fistula in advanced esophageal cancer. In the univariate analysis, gender, therapies for ESCC before the development of fistula, type of esophageal fistula, treatment of esophageal fistula and hemoglobin (Hb) level were the factors with significant prognostic value. Gender, type of esophageal fistula and Hb level were identified as independent prognostic factors in further multivariate analysis. In summary, our study demonstrated that several factors are significantly related to patients with esophageal fistula and should be concerned about in clinical practice.

Primary and Rescue Endoluminal Vacuum Therapy in the Management of Esophageal Perforations and Leaks.

BACKGROUND: To investigate the efficacy of primary and rescue endoluminal vacuum (EVAC) therapy in the treatment of esophageal perforations and leaks. METHODS: We conducted a retrospective review of a prospectively gathered, Institutional Review Board (IRB) approved database of EVAC therapy patients at our center from July 2013 to September 2016. RESULTS: In all, 13 patients were treated for esophageal perforations or leaks. Etiologies included iatrogenic injury (n = 8), anastomotic leak (n = 2), Boerhaave syndrome (n = 1), and bronchoesophageal fistula (n = 2). In total, 10 patients underwent primary treatment and three were treated with rescue therapy. Mean Perforation Severity Scores (PSSs) in the primary and rescue treatment groups were 7 and 10, respectively. Average defect size was 2.4 (range: 0.5-6) cm. The rescue group had a shorter mean time to defect closure (25 vs. 33 days). In all, 12 of 13 defects healed. One death occurred following the implementation of comfort care. One therapy-specific complication occurred. Hospital length of stay (LOS) was longer in the rescue group (72 vs. 53 days); however, the intensive care unit (ICU) duration was similar between groups. Totally, 10 patients (83%) resumed an oral diet after successful defect closure. CONCLUSION: Utilized as either a primary or rescue therapy, EVAC therapy appears to be beneficial in the management of esophageal perforations or leaks.

Characteristics of atrial fibrillation patients suffering atrioesophageal fistula after radiofrequency catheter ablation.

INTRODUCTION: Radiofrequency catheter ablation (RFCA) in atrial fibrillation (AF) patients can cause various complications and atrioesophageal (AE) fistula is one of the most catastrophic complications of RFCA. METHODS AND RESULTS: RFCA registries from 3 cardiovascular centers in the Republic of Korea consisted of 5721 patients undergoing 6724 procedures. Before undergoing RFCA, patients underwent either computed tomography or magnetic resonance imaging. We evaluated clinical, anatomical, and procedural characteristics of patients who developed AE fistula after RFCA. A total of 10 patients developed AE fistula after RFCA (0.15% per procedure). All AE fistulas occurred during first-time RFCA. Eight patients died and mortality rate was 80.0%. No patients had any gastrointestinal symptom at the time of discharge and mean duration time from RFCA to symptom onset was 23.4 days. Six patients (60.0%) had paroxysmal AF. Substrate modification in addition to pulmonary vein isolation was performed in 4 patients (40.0%). Patients with old age, low body weight, and high CHA2 DS2 -VASc score were at increased risk of AE fistula. Baseline imaging evaluation revealed that esophagus had closest contact with LA posterior wall near left inferior pulmonary vein rather than left superior pulmonary vein and all documented AE fistulas were located near left inferior pulmonary vein. CONCLUSION: Posterior wall of LA near left inferior pulmonary vein was the most vulnerable location for AE fistula. Pulmonary vein isolation was the main lesion set associated with AE fistula and old age, low body weight, and high CHA2 DS2 -VASc score were significant risk factors for AE fistula.

Surgical strategy for the treatment of aortoesophageal fistula.

OBJECTIVE: To present a surgical strategy for aortoesophageal fistula (AEF). METHODS: From October 1999 to May 2017, 27 patients with AEF were treated at Kobe University Hospital. After 9 patients with malignancies or fish bone penetration were excluded, 18 patients who had AEF secondary to aortic lesions were investigated. The mean age was 67.2 ± 10.4 years, and the male/female ratio was 16:2. Twelve patients had a nondissection thoracic aneurysm, and 6 patients had a chronic aortic dissection. Six patients were in shock. Seven patients had a previous thoracic endovascular aortic repair (TEVAR) in the descending aorta, 2 patients had descending aorta replacement, 1 had hemiarch replacement, and 2 had total arch replacement. As the first treatment for AEF, 3 patients underwent TEVAR as destination therapy, 3 patients had a bridge TEVAR to open surgery, 1 patient had an extra-anatomical bypass from the ascending aorta to the abdominal aorta, and 11 patients had an in situ reconstruction of the descending aorta. The esophagus was resected in 16 patients, and an omental flap was installed in 16 patients. Additional procedures were extra-anatomical bypass in 2 patients and in situ reconstruction of the aorta in 3 patients. RESULTS: Hospital mortality was noted in 4 patients (22.2% persistent sepsis, n = 3: pneumonia, n = 1). However, since 2007, only 1 of 13 patients has died (pneumonia). Late death occurred in 5 patients, due to pneumonia, cerebral bleeding, diarrhea, sudden death, and persistent infection. Actuarial survival was 42.4 ± 12.8% at 5 years and freedom from aorta-related death was 59.4 ± 13.5% at 5 years. Nine patients achieved completed reconstruction of the esophagus 172 ± 57 days after initial surgery. CONCLUSIONS: Although a comparative study was not performed, 1-stage surgery consisting of resection of an aneurysm and esophagus, in situ reconstruction of the descending aorta, and omental flap installation provided a better outcome in the treatment for AEF. Bridging TEVAR to the open surgery is a useful adjunct in patients with AEF with hemorrhagic shock. Later reconstruction of the esophagus can be performed in the survivors.

Atrioesophageal Fistula: Clinical Presentation, Procedural Characteristics, Diagnostic Investigations, and Treatment Outcomes.

BACKGROUND: Percutaneous or surgical ablation are increasingly used worldwide in the management of atrial fibrillation. The development of atrioesophageal fistula (AEF) is among the most serious and lethal complications of atrial fibrillation ablation. We sought to characterize the clinical presentation, procedural characteristics, diagnostic investigations, and treatment outcomes of all reported cases of AEF. METHODS AND RESULTS: Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73%), neurological (72%), gastrointestinal (41%), and cardiac (40%) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68%), although 7 cases required repeat testing. Overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%) (adjusted odds ratio, 24.9; P<0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P<0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047). CONCLUSIONS: AEF complicating atrial fibrillation ablation is associated with a high mortality. Clinicians should have a high suspicion for the development of AEF in patients presenting with infective, neurological, gastrointestinal, or cardiac symptoms within 2 months of an atrial fibrillation ablation. Investigation by contrast computed tomography of the chest with consideration of repeat testing can lead to prompt diagnosis. Surgical intervention is associated with improved survival rates.

Atrial-oesophageal fistula following percutaneous radiofrequency catheter ablation of atrial fibrillation: the risk still persists.

Aims: Atrial-oesophageal fistula is a serious complication related to ablation of atrial fibrillation. As its occurrence is rare, there is a great lack of information about their mechanisms, incidence, presentations, and treatment. The objective of this manuscript is to present a series of cases of atrial-oesophageal fistula in Brazil, focusing on incidence, clinical presentation, and follow-up. Methods and results: This is a retrospective multicentre registry of atrial-oesophageal fistula cases that occurred in eight Brazilian centres from 2003 to 2015. Ten cases (0.113%) of atrial-oesophageal fistula were reported in 8863 ablation procedures in the period. Most of the subjects were male (70%) with age 59.6 ± 9.3 years. Eight centres were reference units in atrial fibrillation ablation with an experience over than 200 procedures at the time of fistula occurrence. Oesophageal temperature monitoring was performed in eight cases using coated sensors in six. The first atrial-oesophageal fistula clinical manifestation was typically fever (in six patients), with a median onset time of 16.5 (12­43) days after ablation. There was a delay of 7.8 ± 3.3 days between the first manifestation and the diagnosis in five patients. The treatment was surgical in six cases, clinical in three and stenting in one. Seven patients died (70%) and two developed permanent neurological sequelae. Conclusion: Atrial-oesophageal fistula remains a serious complication following AF ablation despite the incorporation of protective measures and increased technical experience of the groups. The high morbidity and mortality despite the treatment indicates the need to develop adequate preventive strategies.

[Application of bundles of intervention in the treatment of esophageal carcinoma anastomotic leak].

OBJECTIVE: To investigate the application of bundles of intervention in the treatment of esophageal carcinoma anastomotic leak. METHODS: From January 2014 to May 2015, 44 cases of esophageal carcinoma anastomotic fistula were treated by bundles of intervention (through the collection of a series of evidence-based treatment and care measures for the treatment of diseases) in Department of Thoracic Surgery, Huai'an First Hospital, Nanjing Medical University (bundles of intervention group), and 68 patients with esophageal carcinoma postoperative anastomotic leak from December 2013 to January 2012 receiving traditional therapy were selected as the control group. The clinical and nutritional indexes of both groups were compared. RESULTS: There were no significant differences in general data and proportion of anastomotic leak between the two groups. Eleven patients died during hospital stay, including 3 cases in bundles of intervention group(6.8%) and 8 cases in control group (11.8%) without significant difference(P = 0.390). In bundles of intervention group, 1 case died of type III( intrathoracic anastomotic leak, 2 died of type IIII( intrathoracic anastomotic leak. In control group, 2 cases died of type III( cervical anastomotic leak, 2 died of type III( intrathoracic anastomotic leak and 4 of type IIII( intrathoracic anastomotic leak. The mortality of bundles of intervention group was lower than that of control group. The duration of moderate fever [(4.1±2.4) days vs. (8.3±4.4) days, t=6.171, P=0.001], the time of antibiotic use [(8.2±3.8) days vs.(12.8±5.2) days, t=5.134, P = 0.001], the healing time [(21.5±12.7) days vs.(32.2±15.8) days, t=3.610, P=0.001] were shorter, and the average hospitalization expenses[(63±12) thousand yuan vs. (74±19) thansand yuan, t=3.564, P=0.001] was lower in bundles of intervention group than those in control group. Forty-eight hours after occurrence of anastomotic leak, the levels of hemoglobin, albumin and prealbumin were similar in both groups. However, at the time of fistula healing, the levels of hemoglobin [(110.6±10.5) g/L vs.(103.8±11.1) g/L, t=3.090, P=0.002], albumin [(39.2±5.2) g/L vs.(36.3±5.9) g/L, t=2.543, P=0.013] and prealbumin [(129.3±61.9) g/L vs.(94.1±66.4) g/L, t=2.688, P=0.008] were significantly higher in bundles of intervention group. CONCLUSION: In the treatment of postoperative esophageal carcinoma anastomotic leak, application of bundles of intervention concept can significantly improve the nutritional status and improve the clinical outcomes.

[Esophago-gastric complications after ablation in atrial fibrillation]. / Complications œsogastriques de la thermoablation dans le cadre de la fibrillation auriculaire.

Atrial-esophageal fistula (AOF) after ablation in atrial fibrillation has a fatal outcome. Fully documented in 2004, AOF has never completely disappeared despite technological evolvements. Survival depends on early recognition and treatment. Gastroscopy allows early detection of esophageal lesions. We summarize here AOF mechanisms, evoking symptoms and treatment ; contribution of gastroscopy in early detection ; and finally symptoms from vagal and phrenic nerve injuries. This information is useful for emergency doctors, gastroenterologists / endoscopists, and general practitioners.

La fistule atrio-œsophagienne (FAO) est une complication dramatique de la thermoablation des foyers ectopiques responsables de fibrillation auriculaire. Depuis sa description en 2004, la FAO n'a pas complètement disparu malgré les évolutions technologiques, comme en témoignent des publications récentes. Néanmoins, reconnue et traitée rapidement, son pronostic s'améliore considérablement. La gastroscopie permet la détection de lésions œsophagiennes (LO) dès les premières 24 heures. Nous résumons les mécanismes et symptômes de la FAO, ainsi que sa prise en charge, le rôle de la gastroscopie dans la détection précoce des LO, et les complications liées à l'atteinte des nerfs vague et phréniques. Ces informations peuvent être utiles aux urgentistes, aux gastroentérologues et aux généralistes.

Infective etiology affects outcomes of late open conversion after failed endovascular aneurysm repair.

PURPOSE: To retrospectively review all patients undergoing late open conversion (LOC) after endovascular aneurysm repair (EVAR) in order to identify any clinical or technical predictors of poor outcome. METHODS: Twenty-six consecutive patients (24 men; mean age 74.7 ± 8.3 years) underwent LOC between June 2006 and April 2013 at our institution. The mean interval from index EVAR to LOC was 40.4 ± 29.2 months (range 5-93 months). The indication for LOC was endoleak in 14 (54%) patients and infection in 12 (46%): 2 (8%) patients with endoleak had a ruptured aneurysm and 6 (23%) patients with infection had a recurrent secondary aortoesophageal fistula (sAEF). RESULTS: In all 12 cases of infection and in 12 of 14 endoleaks, the entire endograft was explanted. A rifampin-soaked Dacron silver graft was implanted in all patients with infection. Patients with any infection and with recurrent AEF required more blood units than patients with endoleak (6.40 vs. 1.86, p = 0.045; 6.76 vs. 1.86, p = 0.0036, respectively). Compared with endoleak, the duration of conversions in the setting of infection (274 vs. 316 minutes, p = 0.42) and recurrent sAEF (274 vs. 396 minutes, p = 0.021) was longer. All patients with recurrent sAEF died at a mean 3.0 ± 2.5 days after LOC from proximal anastomosis disruption and hemorrhagic shock (n = 2), myocardial infarction (n = 2), acute stroke (n = 1), or persistent sepsis (n = 1). Perioperative mortality was significantly higher in patients with endograft infection (6/12, p = 0.002) and in cases of supraceliac cross-clamping (4/6, p = 0.003). The association of infection with supraceliac cross-clamping was a strong predictor for perioperative mortality (p < 0.001). CONCLUSION: In our experience, endograft infection led to greater perioperative mortality after LOC. Recurrent aortoenteric fistula in association with supraceliac cross-clamping is a strong predictor of poor outcome. Patients surviving the perioperative period may have good chances of long-term survival.

Therapeutic strategy for treating aortoesophageal fistulas.

PURPOSE: The development fistulas between the thoracic aorta and the esophagus are highly fatal conditions. We aimed to identify a therapeutic strategy for treating aortoesophageal fistula (AEF) in this study, by investigating all AEF cases presented in this special symposium at the 65th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery. METHODS: Forty-seven AEF patients were included in this study. The survivors and nonsurvivors at six and 18 months after diagnosis of AEF were classified into "Group A6", "Group D6", "Group A18", and "Group D18", respectively. Comparisons between Group A6 and Group D6 and between Group A18 and Group D18 were made with regard to therapeutic strategy. RESULTS: Twenty-two (46.8 %) and 33 (70.3 %) of the 47 patients died within 6 and 18 months, respectively. The patients treated with omentum wrapping (p = 0.0052), esophagectomy (p = 0.0269) and a graft replacement strategy for the aorta (p = 0.002) were more frequently included in Group A6. The patients with the omentum wrapping (p = 0.0174) and esophagectomy (p = 0.0203) and graft replacement were more significantly included in Group A18. The results of the multivariate analysis indicated that the mortality rate at 6 and 18 months after diagnosis was significantly correlated with graft replacement (p = 0.0188) and esophagectomy (p = 0.0257), respectively. There were significant differences in the actuarial survival curves in patients who had omentum wrapping, graft replacement, and esophagectomy compared to patients who did not have these 3 therapeutic procedures. CONCLUSION: The use of thoracic endovascular aortic repair alone for AEF should not be considered a definitive surgery. In contrast, esophagectomy, open surgery with aortic replacement using prostheses and homografts and greater omentum wrapping significantly improve the mid-term survival of AEF.

Predictors of outcome and different management of aortobronchial and aortoesophageal fistulas.

OBJECTIVE: Aortoesophageal and aortobronchial fistulas are uncommon but life-threatening conditions. The present study aimed to identify potential differences in outcomes, depending on the etiology, type, and management of the fistulas, and to determine mortality predictors. METHODS: We retrospectively reviewed a series of 26 consecutive patients with thoracic aorta fistulas admitted to our institution from 1998 to 2013 (18 aortobronchial, 7 aortoesophageal, and 1 combined fistula). RESULTS: The mean age was 61.5 ± 13.4 years, with 22 men. Management was thoracic endovascular aortic repair (TEVAR) in 8, open repair in 7, and conservative in 11. The TEVAR and nonoperative patients were significantly older and presented with more comorbidities. Shock developed in 15 patients and sepsis in 9. The most common radiologic findings were intramural hematoma (65.4%), pseudoaneurysm (53.8%), and bronchial compression (46.20%). Active contrast extravasation (23.1%) and ectopic gas (19.2%) were associated with a worse prognosis. In-hospital mortality was 100% in the conservative group, 37.5% in the TEVAR group, and 14.3% in the open repair group (P = .04). Septic shock was the most common cause of death. The risk factors for in-hospital mortality were hemodynamic instability on admission (P = .02), sepsis (P = .04), and conservative management (P < .001). The overall long-term survival in surgical patients at 1 and 5 years was 66% and 58.7%, respectively. Infectious and malignant etiologies resulted in the worst prognosis. CONCLUSIONS: The outcomes are ultimately conditioned by the etiology of the fistula. Both open and endovascular management of aortic fistulas can prevent death by exsanguination; however, patients remain at high risk of infectious complications. Failure to treat the underlying cause will result in poor midterm outcomes.

Treatment of esophagopleural fistulas using covered retrievable expandable metallic stents.

PURPOSE: To evaluate the clinical efficacy of placement of covered retrievable expandable metallic stents for esophagopleural fistulas (EPFs). MATERIALS AND METHODS: During the period 1997-2013, nine patients with EPF were treated using covered retrievable expandable metallic stents. The underlying causes of EPF were esophageal carcinoma (n = 6), lung cancer (n = 2), and postoperative empyema for Boerhaave syndrome (n = 1). RESULTS: Technical success was achieved in eight patients (88.9%). In one patient, incomplete EPF closure was due to incomplete stent expansion. Clinical success, defined as complete EPF closure within 7 days, was achieved in five patients (55.6%). Overall fistula persistence (n = 1) or reopening (n = 4) occurred in five patients (55.6%) 0-15 days after stent placement. The causes of reopening were due to the gap between the stent and the esophagus (n = 3) or stent migration (n = 1). For fistula persistence or reopening, additional interventional management, such as gastrostomy, stent removal, or stent reinsertion, was performed. Stent migration occurred as a complication in one patient with EPF from a benign cause secondary to postoperative empyema. In the eight patients who died during the follow-up period, the mean and median survival times were 78.8 days and 46 days, respectively. CONCLUSIONS: Placement of a covered expandable metallic esophageal stent for the palliative treatment of EPF is technically feasible, although the rate of clinical success was poor secondary to fistula persistence or reopening. Fistula reopening was caused by the gap between the stent and the esophagus or by stent migration, and additional interventional treatment was useful to ensure enteral nutritional support.

Thoracic endovascular aortic repair in management of aortoesophageal fistulas.

OBJECTIVE: To provide a systematic review of the outcomes of thoracic endovascular aortic repair (TEVAR) for aortoesophageal fistula (AEF) and to identify prognostic factors associated with poor outcomes. METHODS: Literature searches of the Embase, Medline, and Cochrane databases identified relevant articles reporting results of TEVAR for AEF. The main outcome measure was the composite of aortic mortality, recurrence of the AEF, and stent graft explantation. The secondary outcome measure was aortic-related mortality. RESULTS: Fifty-five articles were integrated after a literature search identified 72 patients treated by TEVAR for AEFs. The technical success rate of TEVAR was 87.3%. The overall 30-day mortality was 19.4%. Prolonged antibiotics (>4 weeks) were administered in 80% of patients. Concomitant or staged resection or repair of the esophagus was performed in 44.4% of patients. Stent graft explantation was performed within the first month after TEVAR as a planned treatment in 11.1%. After a mean follow-up of 7.4 months (range, 1-33 months), the all-cause mortality was 40.2%, and the aortic-related mortality was 33.3. Prolonged antibiotic treatment (P = .001) and repair of AEFs due to a foreign body (P = .038) were associated with a significant lower aortic mortality. On univariate analysis, TEVAR and concomitant or staged adjunctive procedures (resection, repair of the esophagus, or a planned stent graft explantation) were associated with a significantly lower incidence of aortic-related mortality (P = .0121). When entered into a binary logistic regression analysis, prolonged antibiotic treatment was the only factor associated with a significant lower incidence of the endpoint (P = .003). CONCLUSIONS: Late infection or recurrence of the AEF and associated mortality rates are high when TEVAR is used as a sole therapeutic strategy. Prolonged antibiotic treatment has a strong negative association with mortality. A strategy of a temporizing endovascular procedure to stabilize the patient in extremis, and upon recovery, an open surgical esophageal repair with or without stent graft explantation is advocated.

The prevalence and risk factors for atrioesophageal fistula after percutaneous radiofrequency catheter ablation for atrial fibrillation: the Canadian experience.

PURPOSE: Atrioesophageal fistula (AEF) is an infrequent complication of radiofrequency (RF) ablation for atrial fibrillation (AF). The aim of this study was to determine the prevalence and operator-dependent factors associated with AEF using a nationwide survey of electrophysiologists (EP). METHODS: Thirty-eight EPs performing AF ablation between 2008 and 2012 were invited to complete a web-based questionnaire assessing the prevalence and factors associated with AEF. RESULTS: Responses were obtained from 25 EPs (68 %) accounting for 7,016 AF ablations. Five cases of proven AEF (0.07 %) were reported. Operators who reported AEF [AEF (+)] more often used general anesthesia (GA) [90 % AEF (+) vs. 44 % AEF (-), p = 0.046]. AEF (+) operators were also more likely to be users of the non-brushing technique in the posterior wall of the LA [5 (100 %) AEF (+) vs. 5 (25 %) AEF (-), p = 0.005]. The combined usage of GA and non-brushing technique during LA posterior wall ablation had a strong association with AEF (+) operators [4 (80 %) AEF (+) vs. 2 (10 %) AEF (-), p = 0.002]. There was a trend towards higher maximal RF energy setting in the posterior wall [47.4 + 7.6 AEF (+) vs. 40.2 + 8 AEF (-), p = 0.09]. Other procedure parameters were similar. CONCLUSIONS: The reported prevalence of AEF among Canadian AF ablators is 0.07 %. AEF was associated with high mortality. The use of GA and non-brushing movements during posterior wall ablation were two factors associated with AEF.

Recurrent oesophageal cancer complicated by tracheo-oesophageal fistula: improved palliation by means of parallel tracheal and oesophageal stenting.

OBJECTIVES: Recurrent oesophageal carcinoma complicated by the development of a tracheo-oesophageal fistula is a crushing condition. In this situation, endoscopic double stenting may provide a quick and safe option for palliation. METHODS: The outcomes of patients who received endoscopic parallel stent implantation for tracheo-oesophageal fistula due to recurrent oesophageal cancer at a German tertiary referral hospital between 2006 and 2013 were reviewed in a retrospective case study. RESULTS: A total of 9 patients were identified (mean age 59.9 years). Tumour entity was squamous cell carcinoma, adenocarcinoma and neuroendocrine cancer of the oesophagus in 5, 3 and 1 case, respectively. The mean interval between primary treatment and recurrence was 19.2 months. Successful double-stent placement was always feasible. Complete closure of the communication between oesophagus and respiratory system was accomplished in all cases by stent implantation. There were no stent-associated complications. The mean survival following stent insertion was 64 days (6-121 days). After successful double stenting, 5 patients were fit enough to receive palliative chemo- or radiotherapy. Seven patients were finally discharged home after adequate oral intake had been achieved. Fatal aspiration pneumonia with respiratory failure occurred in 2 cases. CONCLUSIONS: Endoscopic parallel stent implantation provides an easy and ubiquitous available technique for closure and palliation of tracheo-oesophageal fistula caused by recurrent oesophageal cancer. Immediate sealing of the fistula and relief of symptoms related to aspiration is achieved while hazardous operations are avoided. Therefore, we recommend endoscopic parallel stent insertion as the treatment of choice in case of tracheo-oesophageal fistula caused by recurrent oesophageal cancer.

Non-malignant respiratory tract fistula from the oesophagus. A lethal condition for which novel therapeutic options are emerging.

OBJECTIVES: Fistulas between the oesophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after oesophageal resection, without any signs of local residual tumour growth. Other causes that are, by definition, benign may rarely prevail. The traditional therapeutic approach is to divert the proximal portion of the oesophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. We have evaluated our stent-based strategy for managing these life-threatening situations. METHODS: At Karolinska University Hospital, all patients admitted with an oesophago-respiratory fistula during the period 2003-2011 followed a stent-based strategy. On clinical suspicion, a prompt computed tomography scan was performed with contrast ingestion, to visualize the status of the anastomosis and the potential communications. Often an endoscopy was done to assess the oesophagus and the conduit. The respiratory tree was inspected through a concomitant bronchoscopy. The double-stent strategy presently applied meant that covered self-expandable metal stents (SEMS) were applied on the alimentary and airway sides to adequately cover the fistula orifice on both sides. The subsequent clinical course determined the ensuing therapeutic strategy. RESULTS: During the study period, 17 cases with oesophago-respiratory fistulas were treated at our unit, of which 13 exhibited fistulation following an oesophageal resection due to cancer and 4 cases had a benign underlying disease. The cancer patients did not show any obvious demographic profile when it came to the cancer sub-location, histological type of cancer, or treatment with neoadjuvant chemo- and radiochemotherapy. There was an equal distribution between hand-sutured and stapled anastomoses. In 10 of the cases, the anastomoses were located in the upper right chest; the remainder in the neck, and all reconstructions were carried out by a tubulized stomach. The diagnosis of the fistula tract between the anastomotic area and the respiratory tract was attained on the 15th postoperative day (median), with a range from 5 to 24 days. CONCLUSIONS: When an oesophago-respiratory fistula is diagnosed, even in a situation where no neoplastic tissue is prevailing, attempts should be made to close the fistula tract by SEMS from both directions, i.e. from the oesophageal as well as the respiratory side. By this means, a majority of these patients can be initially managed conservatively with prospects of a successful outcome, although virtually all will eventually require a single-stage resection and reconstruction.

[Emergency interventions for perforation and bleeding in esophageal cancer patients]. / Notfalleingriffe bei Perforation und Blutung beim Ösophaguskarzinom.

Bleeding and perforation in esophageal cancer patients are rare but associated with a high morbidity and mortality. Because of disappointing results after primary surgical exploration and resection endoscopic intervention was introduced as the primary treatment option with an improved outcome. Aortoesophageal and esophagobronchial fistulas may occur spontaneously or secondary to stenting of the esophagus. They are uncommon but fatal if untreated. The first option is prompt placement of a stent graft as a bridging solution followed by surgical treatment.