Gastrotracheal fistula: Treatment with a covered elf-expanding Y-shaped metallic stent

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.

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.

Multiple Bifurcated Covered Self-Expanding Metallic Stents for Complex Tracheobronchial Fistulas or Stenosis

OBJECTIVE

We aimed to determine the safety and feasibility of bifurcated covered self-expanding stents for the treatment of complex tracheobronchial fistulas or stenosis.

METHODS

Twenty-eight patients were treated by multiple bifurcated covered airway stents (Micro-Tech Co. Ltd., Nanjing, China), including 18 cases of gastrobronchial or gastrotracheal fistula, 6 cases of bronchopleural fistula and 4 cases of severe tracheobronchial stenosis. The large bifurcated covered stent was placed at the main carina, and the small stents were inserted into primary right carina or secondary left carina. Clinical and imaging data were retrospectively analyzed.

RESULTS

Stents were successfully inserted in 27 patients at the first attempt. In total, 29 large bifurcated covered stents, 27 small bifurcated covered stents and 5 small bifurcated covered single-plugged stents were inserted. All patients with fistula could resume eating without coughing after the procedure. No perioperative death or severe complications occurred. Two patients underwent stent removal due to intolerance of stenting; the clinical success rate was 93% (26/28). Nineteen complications were found in 12 patients; 8 patients needed stent removal or replacement, for a major complication rate of 29% (8/28). Eight patients underwent successful stent removal due to complications. Fifteen patients died of tumors and one patient died of pulmonary infection. The median survival was 33 months. Fistula recurrence was found in one patient 5 months after stenting, and second small bifurcated covered stent was inserted.

CONCLUSIONS

Multiple bifurcated covered metallic stenting is effective and safe for complex tracheobronchial fistulas or stenosis, with good symptom palliation.

A new technique to repair huge tracheo-gastric fistula following esophagectomy

We reported the management of a life-threatening condition as a large tracheo-gastric fistula involved the carina, the left and the right bronchus that complicated Ivor Lewis esophagogastrectomy for esophageal cancer. An urgent right thoracotomy was performed and the tracheal defect was covered with a reversed pedicled pericardial patch reinforced with an intercostal muscle flap. Cervical esophagostomy and a feeding jejunostomy completed the operation. Five months later, the continuity of gastrointestinal tract was restored using a transverse colon.

Repair of large airway defects with bioprosthetic materials

OBJECTIVE

Patients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of this study was to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects.

METHODS

Retrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic device, namely aortic homograft or acellular dermal matrix.

RESULTS

Eight patients, 3 men and 5 women with a mean age of 54 ± 13 years, underwent closure of complex central airway defects with bioprosthetic material. All but 1 patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, whereas 5 had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n = 5), the anterior wall of the trachea (n = 1), or the main stem bronchus (n = 2). Five reconstructions were with aortic homograft and 3 with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n = 4), omentum (n = 2), or left unbuttressed (n = 2). The airway defect was successfully closed in all patients. There was no postoperative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and 1 additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%).

CONCLUSIONS

Bioprosthetic materials represent a viable option for management of large airway defects, including airway-enteric fistulae, that exceed the limits of primary repair.