Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period

European Journal of Cardio-thoracic Surgery 34 (2008) 1103—1107 www.elsevier.com/locate/ejcts Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period Akos Balazs *, Peter K. Kupcsulik, Zoltan Galambos Department of Surgery, Semmelweis University, Budapest, Üllői u. 78. 1082, Hungary Abstract Objective: Esophagorespiratory fistulas developing from malignant tumors have serious complications by maintaining continuous airway contamination. The objective was to reveal the incidence, causes and characteristics of fistula formation and to examine the possibilities and efficiency of the treatment. Methods: In a single-center study between 1984 and 2004, the data of 2113 patients with tumorous esophageal stenosis were analyzed. Esophagorespiratory fistulas were detected in 264 cases (12.5%). Successful esophageal intubation, stent correction or replacement was performed in 188 cases, while there was one lethal complication. Twenty-seven patients had an intervention for nutritional support: 25 gastrostomies, 1 jejunostomy and 1 percutaneous endoscopic gastrostomy. Results: The mean survival period of all patients was 2.8 months; patients with implanted endoprosthesis 3.4 months; with nutritional support 1.1 months and with only supportive therapy 1.3 months, respectively. The differences between the endoprosthesis implanted group and the other two groups were significant ( p < 0.001). Conclusions: By sealing the fistula, a successful endoscopic esophageal intubation ends the severe respiratory contamination and the inability to swallow, improving the quality of life and survival period. After the procedure, it is the malignant tumor and not the fistula that determines the future of the patient. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. Keywords: Esophageal cancer; Esophagorespiratory fistula; Endoprosthesis; Esophageal stents 1. Introduction Esophagorespiratory fistulas (ERF) are pathological communications between the esophagus and the respiratory tract. In clinical practice ERF is a devastating complication of some malignant diseases. The pathological basis of fistula formation is the spreading of the esophageal cancer into the airways or lungs, or the propagation of pulmonary and mediastinal tumors into the esophagus. Presumably, it occurs more frequently than the 5—10% incidence noted in literature, especially at the end stage of the malignant disease. Its early diagnosis and treatment is extremely important, because sealing the fistula can improve the survival and the quality of life of the patient. Since there are no relevant data about incidence, outcome or complication of ERF, our objective was to evaluate the true incidence of fistula formation, and its effects on patients’ survival. The improvement in the survival and quality of life by the termination of the pathological communication was examined. The relationship between fistula formation and the time of tumor existence, and the * Corresponding author. Tel.: +36 1 313 5216; fax: +36 1 314 3431. E-mail address: (A. Balazs). effects of surgical or other oncological treatment (such as irradiation therapy) were also analyzed. 2. Patients and methods Between 1984 and 2004, 2113 patients with malignant esophageal disease were treated at our institution. Esophagorespiratory fistula was detected in 264 cases: 243 esophageal cancers, 19 pulmonary tumors and 2 mediastinal tumors, respectively. The ratio between men and women was found to be 4.3:1. The mean age of patients with fistula was 56.7 years (range: 21—90; SD: 11.90; CI: 55.3—58.2). The clinical findings of the 264 patients included the signs of severe septic condition besides the general symptoms of a malignant disease. The average time of presentation since the first signs and symptoms was 5.3 months (range: 1—18; SD: 4.38; CI: 4.6—5.7). The degree of dysphagia was found to be: none 7 (2.7%), solid foods: 57 (21.6%), mashy foods: 93 (35.2%), fluids: 107 (40.5%). Odynophagia was present in 51 cases (19.3%), retrosternal pain in 61 cases (23.1%), and fever in 95 cases (36.9%). The mean weight loss was 10.45 kg (range: 0— 25; SD: 7.35; CI: 9.6—11.4), and cachexia was diagnosed in 157 cases (59.5%). All ERF patients suffered from severe 1010-7940/$ — see front matter # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejcts.2008.06.025 Received 19 December 2007; received in revised form 20 May 2008; accepted 11 June 2008; Available online 3 August 2008 1104 A. Balazs et al. / European Journal of Cardio-thoracic Surgery 34 (2008) 1103—1107 Table 1 Extent, location and morphology Extent of the tumor (mean) 7.6 cm (2—18; SD: 4.25; CI: 7.1—8.2) Primary location of the tumor Upper third: Middle third Lower third Whole esophagus involved 46 (17.4%) 186 (70.5%) 31 (11.7%) 1 (0.4%) Respiratory location of the fistula Trachea Bifurcation Right main bronchus Left main bronchus: Lung parenchyma 85 (32.2%) 35 (13.3%) 118 (44.7%) 22 (8.3%) 4 (1.5%) Morphology Stenotizing Axis deviation, angulation Necrotizing cavity Outer compression 180 (68.2%) 21 (7.9%) 53 (13.3%) 28 (10.6%) Fig. 1. Management of the 264 esophagorespiratory fistulas. Prior to fistula development, 41 patients received irradiation therapy either as a preoperative procedure (1 case) or as a palliative indication (40 cases). Low dose-rate (LDR) brachytherapy with intraluminar afterloading method was carried out in 34 patients (6 cases 15 Gy; 13 cases 30 Gy; 13 cases 45 Gy; 2 cases 60 Gy doses respectively). Ten of those patients had endoscopic esophageal intubation previously. Two patients received high dose-rate (HDR) intraluminal afterloading irradiation in 12 and 24 Gy doses. One patient received irradiation by LDR method in 15 Gy doses and by external beam of 56 Gy in combination. Four patients received external irradiation therapy (40 Gy, 60 Gy, 60 Gy, 64 Gy doses respectively). Prior to irradiation therapy, bronchoscopic examination detected no sign of respiratory tract involvement in 35 cases, protuberance of the pars membranacea in 4, and hyperemic reaction in 2 patients. Fistula formation among patients, who underwent irradiation therapy, was proven after an average time of 4.4 months (range 1—13; SD: 2.98; CI: 3.5—5.4), comprising of fistula development after less than 4 weeks in four cases (LDR 15 Gy two patients, 30 Gy one patient, and 45 Gy one patient). Prior to fistula formation 18 patients received chemotherapy, one of them for neoadjuvant purpose and 4 in combination with irradiation (2 HDR and 2 LDR). After fistula manifestation none of the patients received irradiation or chemotherapy. Registration of all the data of the patients was prospective. Statistical analysis was performed using the SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA). The differences between the therapeutic groups wer (...truncated)