Comparative Study of Esophageal Stent and Feeding Gastrostomy/Jejunostomy for Tracheoesophageal Fistula Caused by Esophageal Squamous Cell Carcinoma

et al. (2012) Comparative Study of Esophageal Stent and Feeding Gastrostomy/Jejunostomy for Tracheoesophageal Fistula Caused by Esophageal Squamous Cell Carcinoma. PLoS ONE 7(8): e42766. doi:10.1371/journal.pone.0042766 Comparative Study of Esophageal Stent and Feeding Gastrostomy/Jejunostomy for Tracheoesophageal Fistula Caused by Esophageal Squamous Cell Carcinoma Chien-Ting Liu 0 Yen-Hao Chen 0 Shau-Hsuan Li 0 Yi-Chun Chiu 0 Hung-I Lu 0 Cheng-Hua Huang 0 Kun-Ming Rau 0 Chulso Moon, Johns Hopkins University, United States of America 0 1 Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, 2 Department of Hepato-Gastroenterology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, 3 Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine , Kaohsiung , Taiwan Background: A malignant tracheoesophageal/bronchoesophageal fistula (TEF) is a life-threatening complication of esophageal squamous cell carcinoma. A feeding gastrostomy/jejunostomy had been the most common treatment method for patients with TEF before the era of stenting. The aim of this retrospective study is to compare the prognosis of esophageal squamous cell carcinoma patients with TEF treated with an esophageal metallic stent to those treated with a feeding gastrostomy/jejunostomy. Methods: We retrospectively reviewed a total of 1011 patients with esophageal squamous cell carcinoma between 1996 and 2011 at Kaohsiung Chang Gung Memorial Hospital, and 86 patients with TEF (8.5%) were identified. The overall survival and other clinical data were compared between 30 patients treated with an esophageal metallic stent and 35 patients treated with a feeding gastrostomy/jejunostomy. Results: Among the 65 patients receiving either an esophageal metallic stent or a feeding gastrostomy/jejunostomy, univariate analysis showed that treatment modality with an esophageal metallic stent (P = 0.007) and radiotherapy treatment after fistula diagnosis (P = 0.04) were predictive of superior overall survival. In the multivariate comparison, treatment modality with an esophageal metallic stent (P = 0.026, odds ratio: 1.859) represented the independent predictive factor of superior overall survival. There were no significant differences between groups in mean decrease in serum albumin or mean body weight loss. Compared to the feeding gastrostomy/jejunostomy group, a significantly higher proportion of patients in the stenting group (53% versus 14%, P = 0.001) were able to receive chemotherapy within 30 days after fistula diagnosis, indicating better infection control in the stenting group. Conclusions: Compared with a feeding gastrostomy/jejunostomy, an esophageal metallic stent significantly improves overall survival in patients with malignant TEF in our retrospective analysis. Esophageal metallic stent placement may be considered the first-line of treatment for patients with malignant TEF. - Funding: This work was supported in part by grants from the National Science Council, Taiwan (NSC 100-2314-B-182A-044-MY3) and Chang Gung Memorial Hospital (CMRPG8B0431). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript Competing Interests: The authors have declared that no competing interests exist. . These authors contributed equally to this work. A malignant tracheoesophageal/bronchoesophageal fistula (TEF) is a pathological communication between the esophagus and the respiratory tract; it is a serious and life-threatening complication of esophageal cancer (Figure 1). 5%10% of patients with esophageal cancer contract TEF [1,2]. Most TEFs are caused by a tumor invasion or as a complication of cancer therapies, such as radiotherapy or chemotherapy [2,3]. Malnutrition, frequent aspiration to the airway and repeated pneumonia episodes can lead to rapid deterioration, and the patient will soon die of respiratory failure if not treated in time. Most patients died from respiratory infections and poor nutrition within 34 months [2,4]. Treatment of the malignant TEF is usually palliative and involves restoration of the swallowing mechanism and prevention of aspiration, including surgical resection/repair of the fistula, esophageal bypass, feeding gastrostomy/jejunostomy, stenting, best supportive care, or radiotherapy [1,2,5,6]. Surgical intervention, such as surgical resection/repair of the fistula, is seldom performed nowadays because it carries high mortality and morbidity [6] and thus is only executed in a small number of experienced centers. A feeding gastrostomy/jejunostomy had been considered the ultimate choice to treat TEF before the era of stenting because gastrostomy/jejunostomy can at least partially palliate the respiratory symptom and establish a route of nutritional supply [5,7,8,9,10]. Hu et al. [5] reported that 9 of 35 patients (26%) with malignant tracheoesophageal/bronchoesophageal fistula received gastrostomy. In the series of Choi et al. [9], gastrostomy was performed in 20 of the 52 esophageal squamous cell carcinoma patients (38%) with esophagorespiratory fistula. Since the 1990s, esophageal intubation with stent prostheses has gradually developed. Several types of covered expandable metallic stents have been used with higher rates of complete closure of TEF, which can avoid certain complications, such as hemorrhage, perforation, pressure necrosis, food impaction, stent dislocation, occlusion, and migration [3,11,12,13,14,15]. In Taiwan, feeding gastrostomy/jejunostomy and stenting have become the most common treatment modalities for TEF. Previous studies reported that stent prostheses implantation could improve fistula closure, symptoms of respiratory tract, and quality of life [1,5,11,16,17,18]. However, to the best of our knowledge, compared with the feeding gastrostomy/jejunostomy, the survival benefit of esophageal metallic stent has not yet been well documented. Thus, the aim of this study is to compare the prognosis of patients with malignant TEF who receive an esophageal metallic stent to those who receive a feeding gastrostomy/jejunostomy. Esophageal metallic stent Feeding gastrostomy/jejunostomy No. of patients (%) Materials and Methods Patient Selection 1011 patients with esophageal squamous cell carcinoma at Kaohsiung Chang Gung Memorial Hospital between January 1996 and December 2011were retrospectively reviewed. Diagnoses of TEFs were established using upper gastrointestinal endoscopy, or bronchoscopy, or upper gastrointestinal barium series. Patients suspected as having TEF on a computed tomography (CT) of the chest were excluded if the fistula was not proven by one of the above mentioned methods. The tumor stages were determined according to the 7th American Joint Committee on Cancer (AJCC) staging system. Of t (...truncated)