Covered SEMS failed to cure airway fistula closed by an amplatzer device.

BACKGROUND: Airway fistula is a rare but threatening complication associated with high rates of morbidity and mortality. We report the experience of Amplatzer device application in airway fistulae that failed to be cured with a covered self-expandable metallic stent (SEMS). MATERIALS AND METHODS: Patients who failed occlusion with a covered self-expandable metallic stent and received Amplatzer device placement from Jan 2015 to Jan 2020 were retrospectively enrolled. A total of 14 patients aged 42 to 66 years (55.14 ± 7.87) were enrolled in this study. The primary diseases, types of fistula, types of stents, duration, size of fistula, and follow-up were recorded. RESULTS: All 14 patients with airway fistula failed to be occluded with a covered metallic stent and received Amplatzer device placement. Among the 14 patients, 6 had BPF, 3 had TEF and 5 had GBF. The average stent time was 141.93 ± 65.83 days. The sizes of the fistulae ranged from 3 to 6 mm. After Amplatzer device placement, the KPS score improved from 62.14 ± 4.26 to 75.71 ± 5.13 (P < 0.05). No procedure-related complications occurred. During the 1-month, 3-month and 6-month follow-ups, all the Amplatzer devices were partially surrounded with granulation. Only 1 patient with BPF failed with Amplatzer device occlusion due to the recurrence of lung cancer. CONCLUSION: In conclusion, the application of the Amplatzer device is a safe and effective option in the treatment of airway fistula that failed to be occluded with SEMSs.

Are single or dual luminal covered expandable metallic stents suitable for esophageal squamous cell carcinoma with esophago-airway fistula?

BACKGROUND: To analyze the outcomes of single or dual luminal self-expandable covered metallic stents (SECMS) for palliative treatment for esophageal cancer with esophago-airway fistula (EAF). METHODS: We retrospectively assessed 50 patients who underwent SECMS placement for malignant EAF at our institution between June 2005 and December 2014 to define clinical results of stenting. Treatment provided was classified into initial single airway, single esophageal, or double stent placement. Independent associations between size, location of the EAF, patient's condition, and the risk of migration or reopening with the different types of stenting were examined using logistic regression analysis. RESULTS: The final management of malignant EAF was esophageal stent in 21 patients, airway stent in 13, and dual stents in 16. No patients failed stenting. During a median follow-up of 178 days (range 1-893 days), the fistula reopened in 33 (66 %) of 50 patients. No factors, including fistula size, location, or initial selection of single or dual stenting, were correlated with reopening. Nineteen (57.6 %) of 33 patients needed restenting, and the reopened EAF was sealed off successfully in 52.6 % of new stent placements. The clinical failure of EAF closure was correlated only with proximal dilated esophagus (p = 0.013). Mean survival in patients with clinical success of EAF closure was also significantly longer than that in patients with clinical failure (242.0 vs. 80.1 days, p < 0.001). KPS (p = 0.026), cough ability (p = 0.004), successful closure of EAF (p = 0.001), and reopening (p = 0.007) all had significant effects on survival. CONCLUSIONS: We conclude that SECMS is safe and effective in the palliation of esophageal cancer with malignant EAF, especially in patients with an otherwise excellent general condition. Other modalities of management are recommended for malignant EAF with proximal dilation of the esophagus.

Potential risk factors and outcomes of fistulas between the upper intestinal tract and the airway following Ivor-Lewis esophagectomy.

Fistulas between the upper intestinal tract and the airway following esophagectomy are a rare and severe complication with significant mortality. Treatment and therapy are difficult and require a multidisciplinary approach. The objective of this retrospective study was to identify risk factors for these fistulas following esophagetcomy, and to assess their impact on the further clinical course and outcome. 211 patients undergoing Ivor-Lewis esophagectomy for esophageal cancer between 2005 and 2012 were included. The preoperative risk factors including the risk score according to Schröder et al. and the O-Physiological and Operative Severity Score (POSSUM) score, operative and postoperative parameters and the outcome were evaluated. 65% of all patients developed postoperative complications, including 12 patients that developed fistulas between the upper intestinal tract and the airway (airway fistulas [AF]; 5.6%). Neither patient related risk factors nor esophagus-specific risk scores correlated with occurrence of AF. Furthermore, surgical treatment and neoadjuvant treatment did not show any effect on development of AF in our patients. However, we could demonstrate that AF significantly impacted on length of hospital stay (AF 52 days vs. No-AF group 16 days, P < 0.001), incidence of major pulmonary complications (83.3% vs. 17.1%, P < 0.001), 90-day mortality (42% vs. 7.5%, P = 0.002) and overall survival (133 days vs. 636 days, P=0.029). With the current study, we could not identify any patient related risk factors, esophagus-specific risk scores or treatment related details that might be useful as predictors of AF after Ivor-Lewis esophagectomy. However, we confirmed that AF significantly impacted on outcomes. This highlights the urgent need for further studies on this rare but devastating complication after esophagectomy.

Simultaneous dual scope endotherapy of esophago-airway fistulas and obstructions.

Management of esophago-airway fistulas (EAF) and obstructions often involves therapy with esophageal and/or airway stents. We present a unique approach for the management of EAF and obstructions with simultaneous upper endoscopy and bronchoscopy (two scopes inserted simultaneously through the mouth). The aim is to assess the efficacy and safety of a simultaneous dual scope approach for management of EAF and obstructions. The endoscopy database at the University of Florida was reviewed from October 2007 to April 2012 to identify adult patients who had undergone simultaneous upper endoscopy and bronchoscopy for EAF and obstructions. Medical records were reviewed for demographics, indication, pathology, imaging, simultaneous endoscopic and bronchoscopic findings/maneuvers, outcomes, and adverse events. Outcomes assessed included: (i) technical success, (ii) fistula occlusion, (iii) dysphagia score, and (iv) adverse events. Thirteen patients with EAF and/or obstruction underwent simultaneous dual scope endoscopy. Dual scope procedures were technically successful in 12/13 (92%) patients. Dysphagia score improved from three to one in both patients with dysphagia without EAF. Fistula occlusion was observed in 7/10 patients (70%) with EAF. With this technique, stents were placed accurately without airway compression, migrated esophageal stents extracted from the tracheal lumen without trauma, and tracheal stents not displaced during esophageal manipulations. EAF not otherwise apparent were identified in two patients. Adverse events occurred in 2/13 (15%) patients, and 5/13 (38%) patients died from advanced cancer during follow up (mean 4.1 months, range 1-8 months). Simultaneous dual scope (two scopes inserted through the mouth at the same time) therapy of EAF and obstructions is feasible, effective, and safe, and may develop to be the preferred approach for the management of complex esophago-airway diseases.

Management of neo-esophagus-airway fistula after esophagectomy for oesophageal cancer: systematic literature review and meta-analysis.

OBJECTIVES: Neo-oesophageal-airway fistula (NEAF) between gastric conduit and airway is a rare but life-threatening complication of oesophagectomy for oesophageal cancer. Optimal treatment remains unknown. A meta-analysis of good-quality case series may help determine whether nonoperative management (NOM) only, upfront surgery (S), or NOM followed by surgery is associated with better 1-year post-treatment mortality, resumption of oral diet and fistula recurrence. METHODS: We systematically searched PubMed, EMBASE and Web of Science for publications in English reporting case series of management and survival in patients with NEAF. Of the 177 identified studies, 62 were duplicates and 95 were not relevant to our topic. Three studies were excluded after a full-text review, due to absence of reporting of 1-year survival. Exclusion criteria to identified publications were: abstract only, malignant NEAF, absence of oesophagectomy and esogastric anastomosis, fewer than 5 patients and NEAF not the main focus of the study. Data-extraction was conducted in accordance with MOOSE guidelines. Data were pooled using random-effects model. RESULTS: Seventeen studies (302 patients) were included. One-year post-treatment mortality was considerably lower with NOM followed by surgery [33%; 95% confidence interval (CI), 0.17-0.48] than with NOM (68%; 95% CI, 0.39-0.97) or S (67%; 95% CI, 0.36-0.98). Fistula location was not associated with 1-year mortality. Neither resumption of an oral diet nor fistula recurrence differed significantly across treatment strategies. CONCLUSIONS: NOM to prepare patients for surgery followed by surgical repair may provide the highest 1-year survival of patients with NEAF. However, patient selection criteria to each of 3 treatment strategies may have affected our findings.

Surgical cervicothoracic-flap repair of neoesophagus-airway fistula after esophagectomy for esophageal cancer: A retrospective cohort study.

Objective: To evaluate outcomes of surgical repair of postesophagectomy neoesophagus-airway fistulas (NEAFs). Methods: We retrospectively included consecutive patients with NEAF managed by various techniques at our center between August 2009 and July 2021. Result: Of the 11 patients (median age, 60 years; interquartile range, 58, 62), 4 had received induction chemoradiotherapy and 4 others induction chemotherapy. NEAF was mainly a complication of anastomotic leakage (n = 6) or attempted stenosis treatment (n = 3). The airway mainly involved was the trachea (n = 8). Airway defects were repaired by resection-anastomosis (n = 5), perforator flaps (n = 4), pedicled pericardium (n = 1), and/or direct suturing (n = 2). Gastric conduit defects were repaired by perforator flaps (n = 6), direct suturing (n = 2), or pedicled pericardium (n = 1). Of the 7 perforator flaps, 4 were internal mammary-artery, two dorsal intercostal-artery, and one supraclavicular-artery flaps. After a median follow-up of 100 months, 2 patients died on early postoperative course from NEAF repair failure and 3 from late NEAF recurrence at 4, 11, and 33 months. Among the remaining 6 patients, 1 died from local tumoral recurrence at 13 months, 1 was last on follow-up at 27 months, alive and eating normally. The other 4 were free from NEAF recurrence and dysphagia or swallowing disorder at 50 months' follow-up. These 4 results were obtained thanks to perforator flap interposition and airway resection anastomosis. Conclusions: Surgical NEAF repair using perforator flap interposition may provide satisfactory long-term function after strong prehabilitation.

Treatment of Esophago-Airway Fistula after Esophageal Resection.

(1) Background: Esophago-airway fistula after esophageal resection is a rare, life-threatening complication associated with a high postoperative mortality rate. Managing this condition is challenging, and the prognosis for patients is uncertain. The results and our own approach to treatment are presented. (2) Material and Methods: We present a retrospective analysis of a group of 22 patients treated for an esophago-airway fistula between 2012 and 2022, with 21 cases after esophageal resection and one during the course of Hodgkin's disease. (3) Results: Twenty-two patients were treated for an esophago-airway fistula. Among them, a tracheobronchial fistula occurred in 21 (95.4%) patients during the postoperative period, while 1 (4.5%) was treated for Hodgkin's disease. Of these cases, 17 (70.7%) patients underwent esophageal diversion with various treatments, including intercostal flap in most cases, greater omentum in one (4.5%), latissimus dorsi muscle in two (9%), and greater pectoral muscle in one (4.5%). Esophageal stenting was performed in two patients (9.0%), and one (4.5%) was treated conservatively. Unfortunately, one patient (4.5%) died after being treated with bronchial stenting, and two (9.5%) experienced a recurrence of the fistula. (4) Conclusions: The occurrence of an esophago-airway fistula after esophagectomy is a rare but life-threatening complication with an uncertain prognosis that results in several serious perioperative sequelae.

Case Report: Differential lung ventilation with jet ventilation via a bronchial blocker for a patient with a large thoracogastric airway fistula after esophagectomy.

Background: A thoracogastric airway fistula (TGAF) is a rare and potentially fatal complication of esophagectomy for esophageal and cardia carcinomas. Isolation of the fistula and pulmonary separation is necessary during the surgical repair of a tracheal fistula. However, currently, the reported airway management techniques are not suitable for patients with a large TGAF. This case study presents an alternative technique for performing differential lung ventilation in a patient with a thoracogastric airway fistula. Case presentation: A 70-year-old man was diagnosed with a thoracogastric airway fistula situated above the carina after esophagectomy, and a thoracoscope-assisted repair of the fistula and pectoralis major myocutaneous flap transplantation were scheduled. The patient could not tolerate one-lung ventilation and the complex intubating operation due to aspiration pneumonia and the size (3.5 cm × 1.7 cm) of the fistula. We, therefore, performed differential lung ventilation in which an extended 6.5#single-lumen endotracheal tube was inserted into the left main bronchus and a 9Fr bronchial blocker was placed in the right main bronchus by using the video-flexible intubation scope. The right lung was selectively inflated with jet ventilation, while positive pressure ventilation was maintained through the left endotracheal tube. The value of SPO2 remained above 95% throughout the operation. Conclusion: For patients with a large thoracogastric airway fistula, differential lung ventilation of a combination of positive pressure ventilation and jet ventilation is useful. Inserting an extended single-lumen endotracheal tube into the left main bronchus and a bronchial blocker into the right main bronchus could be another way of providing differential ventilation for patients with a large thoracogastric airway fistula.

The clinical characteristics, treatments and prognosis of post-esophagectomy airway fistula: a multicenter cohort study.

Background: Post-esophagectomy airway fistula (PEAF) is a serious complication after esophageal cancer resection. At present, the clinical characteristics, treatments and prognosis of PEAF patients remain inconclusive. We aimed to investigate these problems of patients with PEAF through a multi-center retrospective cohort study. Methods: We included consecutive patients who underwent esophagectomy for esophageal cancer in seven major Chinese esophageal cancer centers from January 2010 to December 2020. Based on the anatomic characteristics of PEAF patients, PEAFs were divided into Union type I (without digestive fistula) and Union type II [respiratory-digestive fistula (RDF)], and subtypes a and b (tracheal or bronchial fistulas), as well as L1 and L2 (same or different level of fistulas). The clinical characteristics, diagnoses, managements, and effects of the various types were retrospectively analyzed. Results: PEAF occurred in 85 of 26,608 patients (0.32%), including eight females and 77 males. There were 16 patients with type I and 69 with type II. The numbers of healings, non-healings, and deaths at discharge were 45 (52.9%), 20 (23.5%), and 20 (23.5%), respectively. Type Ib was common in type I, and type II L1 was common in type II. The healing rates of surgical, stent, and conservative treatments were 50%, 60%, and 50%, respectively. All type I patients treated with stent implantation were healed at discharge. The healing rates, mortality, and 3-year survival of type II L1 and type II L2 patients were 55.4% and 30.8%, 17.9% and 30.8%, and 34.3% and 15.4%, respectively. The 5-year survival rates of all PEAFs were 21.1%. Conclusions: PEAF is an infrequent and life-threatening complication after esophagectomy. Patients with different types of PEAF often have different inducements. In this study, we found that the healing rates of surgical and conservative treatments were similar, and stent implantation may have the potential to improve efficacy. Type II L2 patients were the most difficult to cure.

Treatment of aerodigestive fistulas with a novel covered metallic Y-shaped segmented airway stent customized with the assistance of 3D printing.

BACKGROUND: The management of aerodigestive fistula remains challenging. An airway stent that matches well with the individual geometry of the airway is needed for the treatment of the aerodigestive fistula. This study aimed to evaluate the feasibility of a novel covered metallic segmented Y-shaped airway stent customized with the assistance of 3D printing in aerodigestive fistulas involving the carina and distal bronchi and to compare the flexibility of the novel stent with the conventional wholly knitted stent. METHODS: In the flexibility study, we measured the longitudinal bending force and spring-back force of the segmented stent and wholly knitted stent. Patient-specific stents that were individually customized with the assistance of 3D printing technology were implanted in 26 patients with aerodigestive fistulas. The technical success, clinical success, Karnofsky performance status (KPS), and stent-related complications were recorded. RESULTS: The bending force and spring-back force of the segmented stent were significantly lower than those of the wholly knitted stent. Stent deployment was technically successful in all patients. Clinical success was obtained in 21 patients. The KPS of patients after the stenting procedure improved significantly compared with that before stenting (P<0.001). During follow-up, granulation tissue proliferation, sputum retention, stent migration, and intolerance of the stent were found in 2, 5, 1, and 1 patient, respectively. CONCLUSIONS: The segmented metallic Y-shaped airway stent had greater flexibility than the wholly knitted stent in an ex vivo setting. Implantation of the segmented stent individually customized with the aid of 3D printing is feasible in treating aerodigestive fistulas involving the carina and bronchi distal to the carina.

Clinical outcomes and survival following placement of self-expandable metallic stents for central airway stenosis and fistula.

BACKGROUND: Self-expandable metallic stent (SEMS) placement is an urgent procedure for patients with malignant central airway stenoses (CASs) and central airway fistulas (CAFs). The aim of this study was to determine the outcome and survival after SEMS placement in patients with malignant CASs and CAFs. METHODS: SEMSs were inserted into 20 patients with malignant CASs and four with malignant CAFs. Hospital records, the modified Medical Research Council dyspnea scale (mMRC) grade, performance status (PS), symptoms, procedure-related complications and survival after placement were retrospectively reviewed. RESULTS: Spiral Z stents were inserted in nine patients, covered Ultraflex stents in 14, and a bare Ultraflex in one patient. After SEMS placement, 20 patients (83.3%) showed improvement in mMRC grade, 19 (79.2%) showed improvement in PS, and 21 (87.5%) showed improvement in symptoms. There were three patients whose stents migrated out of place, but there were no patients with obstructive granulation, infection, or mucous plugs. Median survival days after stent insertion was 98 days for CAS and 103 days for CAF, and mean survival days was 383 ± 707 days for CAS and 93 ± 33 days for CAF. Two patients with CAS by malignant lymphoma and thymic cancer survived more than six years because they were also treated with efficient therapies. The five-year survival rate after stent insertion was 7.7%. CONCLUSIONS: SEMS placement for CAS and CAF is associated with improvement in mMRC grade, PS and symptoms in 87.5% of patients. Patients with a malignant CAS are usually terminal, but the possibility of increasing survival rate will become a reality with new efficient therapies. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Reasonable clinical outcomes and improved survival of patients following SEMS placement for thoracic malignancy with central airway stenosis and fistula. WHAT THIS STUDY ADDS: The possibility of increasing survival rate will become a reality with new efficient therapies.

Management of thoracogastric airway fistula after esophagectomy for esophageal cancer: A systematic literature review.

BACKGROUND: Thoracogastric airway fistula (TGAF) is a serious complication of esophagectomy for esophageal cancer. We conducted a systematic review of the appropriate therapeutic options for acquired TGAF. METHODS: We performed a literature search to identify relevant studies from PubMed, EMBASE, and Web of Science using the search terms "gastric airway fistula", "gastrotracheal fistula", "gastrobronchial fistula", "tracheogastric fistula", "bronchogastric fistula", "esophageal cancer", and "esophagectomy". RESULT: Twenty-four studies (89 patients) were selected for analysis. Cough was the main clinical presentation of TGAF. The main bronchus was the most common place for fistulas (53/89), and 29 fistulas occurred in the trachea. Almost 73% (65/89) of patients underwent non-surgical treatment of whom 87.7% (57/65) received initial fistula closure. Twenty-three patients underwent surgery, including 19 (82.6%) with initial closure. The 1-, 2-, 3-, 6-, and 9-month survival rates in patients who underwent surgical repair were 95.65%, 95.65%, 82.61%, 72.73%, and 38.10%, respectively, and the equivalent survival rates in patients with tracheal stent placement were 91.67%, 86.67%, 71.67%, 36.96%, and 13.33%, respectively. CONCLUSION: TGAF should be suspected in patients with persistent cough, especially in a recumbent position or associated with food intake. Individualized treatment should be emphasized based on the general condition of each patient.

Direct and indirect CT imaging features of esophago-airway fistula in adults.

BACKGROUND: Esophago-airway fistula (EAF) is an abnormal connection between the esophagus and the trachea or a major bronchus. While contrast esophagography remains the primary radiographic tool for the diagnosis of EAF, computed tomography (CT) is often employed in its evaluation. A systematic analysis of CT findings of EAF in adults has not been previously published. The goal of our study is to determine the direct and indirect CT findings of EAF in adults. METHODS: We identified patients with EAF detected on CT at our institution between January 1, 2001 and December 31, 2019, with endoscopic or surgical confirmation. We collected patient clinicopathologic characteristics and assessed CTs for direct and indirect imaging features of EAF in these patients. RESULTS: Twenty-six patients (median age: 56 years; range, 25-79 years; F=13, 50% and M=13, 50%) with confirmed EAF were identified. Half of the patients had an underlying malignancy. On CT, a direct connection between the esophagus and the airway was identified in most cases (22/26; 85%). Common indirect CT findings of EAF included esophageal wall thickening (21/26, 81%), mediastinal fatty stranding (21/26, 81%), airway wall thickening (20/26, 77%), fluid or debris within the airways (17/26, 65%), and focal or diffuse esophageal dilation with air (17/26, 65%). Mediastinal fluid collections were infrequently seen (4/26, 15%), but findings of aspiration or other pneumonia were common (19/26, 73%). CONCLUSIONS: CT plays an essential role in both the primary and secondary evaluation of adult EAF resulting from both malignant and benign etiologies. CT may be the first diagnostic exam to suggest and detect the presence of EAF and may precede clinical suspicion, and it can detect a subset of fistulas not demonstrated on esophagography. There are several direct and indirect imaging findings on CT that can help in the detection of EAF.

Single application of airway stents in thoracogastric-airway fistula: results and prognostic factors for its healing.

BACKGROUND: Thoracogastric-airway fistula (TGAF) post-thoracic surgery is a rare and challenging complication for esophagectomy. The aim of this study was to explore the effectiveness of airway stenting for TGAF patients and find related factors coupled with healing of fistula. METHODS: This is a retrospective study involving patients with TGAF who were treated with airway stentings. Based on different TGAF locations and sizes on chest computed tomography, covered metallic or silicon airway stents were implanted to cover orifices under interventional bronchoscopy. TGAF healing was defined as the primary outcome, and complete sealing of TGAF as the second outcome. The predictors for TGAF healing were analyzed in univariate and multivariate analysis. RESULTS: A total of 58 TGAF patients were included, of whom 7 received straight covered metallic stents, 5 straight silicon stents, 3 L-shaped covered metallic stents, 21 large Y-shaped covered metallic stents, 17 large Y-shaped silicon stents, and 5 with Y-shaped covered metallic stents. Healing was achieved in 20 (34.5%) patients, and complete sealing in 45 (77.6%) patients. There were no significant differences in healing rate and complete sealing rate between patients receiving metallic stents and those with silicon stents. In univariate analysis, lacking a previous history of radiotherapy or chemotherapy, nonmalignant fistulas, small fistulas, and shorter postesophagectomy duration were found associated with a higher rate of TGAF healing. Only shorter postesophagectomy duration was associated with TGAF healing in multivariate analysis. CONCLUSIONS: Both silicon and covered metallic airway stenting are effective methods to close TGAF. A shorter postesophagectomy period may predict better TGAF healing. The reviews of this paper are available via the supplemental material section.