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Malignant TOF
Malignant Tracheo-oesophageal fistula (MTOF)
What are the types of aero digestive tract fistulas?
Tracheo-oesophageal fistula (TOF)
Broncho- oesophageal fistula (BOF)
Oesophageal-lung parenchyma fistulas (rare)
What are the causes of these fistulas?
How common is it?
It develops in approximately 5%–15% of patients with an oesophageal malignancy and in less than 1% of those with bronchogenic carcinoma
What are the symptoms?
Intractable cough and repeated aspirations.
Autopsy data indicate a higher incidence of fistulas, thus suggesting that fistulas are more common in patients than is usually diagnosed. A history of repeated coughing associated with eating, drinking, or both, with an increase in dysphagia and dyspnea are highly suggestive of a fistula. Endoscopic findings are sometimes inadequate in demonstrating a fistula, in which case a water contrast swallow is required.
Lung abscess is the most frequent and severe complication of oesophageal-lung parenchyma fistulas. In this particular type of aero digestive fistula, stent placement may worsen the infectious problem by impairing natural drainage of the abscess.
In one study, lung abscesses decreased in size, but persisted even after stent placement. Concomitant abscess drainage procedures should thus be considered. Thus, oesophageal stent remains the accepted treatment for oesophageal-lung parenchyma fistulas (with percutaneous drainage of the abscess)
What is the prognosis?
Once a fistula (stage T4) develops, the tumour is incurable. The treatment is palliative to alleviate symptoms. Treatment should be begun immediately after the diagnosis is confirmed since the usual cause of death in these patients is pulmonary sepsis resulting from chronic aspiration through the fistula. In two, large series reports (4, 5), mean patient survival was reported to be 3.1-3.4 months. The usual causes of death are: massive bleeding, pneumonia or malnutrition
What are the treatment options?
Therapy is mainly directed to palliate symptoms and maintain quality of life.
Discuss selection of stent?
Several kinds of covered oesophageal stents are available (i.e., Ultraflex stent, Wallstent, and Z stent). However, there are no randomized or controlled trials to compare the outcomes of any of these stents when used to treat malignant aero digestive fistulas
Discuss the stenting area?
The selection guide for determining the stenting area could be summarized as follows:
but with no or only mild airway stricture since an oesophageal stent can successfully treat both oesophageal stricture and a fistula;
NB: Airway stent is preferred in malignant fistula developing after Ivor Lewis
Oesophagectomy (the replaced stomach or colon shows a large lumen compared
with the lumen of the original oesophagus). The larger lumen makes oesophageal stent migration (and hence uncovering fistula) easier.
Discuss double stenting i.e. both oesophageal and Tracheobronchial stent insertion?
Double stenting appear to provide more benefits than either oesophageal or respiratory stents alone in terms of palliation and safety. Double stenting is definitely indicated when fistula occlusion is not achieved by the oesophageal or airway stent alone. In cases of double stenting, airway stent should be placed first in order to avoid tracheal or bronchial compression secondary to the oesophageal stent.
Mechanical friction between the oesophageal and airway stents may cause pressure necrosis of the interposed tissue between the two stents, thereby possibly resulting in a fatal haemorrhage. Thus, parallel stenting should only be performed after thoroughly reviewing a patient’s clinical indications.
Discuss the success of oesophageal stenting?
Does stenting have a survival advantage?
A recent study (3) compared treatment of MTEF in three groups: oesophageal stent group, gastrostomy group and control group (refused both stenting and gastrostomy).
There was no statistical difference in survival time (Average survival time for stent group was 93 days with a range of 44-165 days, gastrostomy group- 62 days, range 41-111 days and control group survival time was 66 days- range 20-119 days).
In two, large series reports (4, 5), mean patient survival was reported to be 3.1-3.4 months. In one of these reports (4), the survival benefit was significant in patients in the stenting group (3.4 months) compared with the gastrostomy group (1.1 months), and the supportive management group (1.3 months).
NB: It is very important to carefully evaluate the airway stenosis with CT scans or
bronchoscopy prior to oesophageal stent placement, since it is possible to develop tracheal compression caused by expanding oesophageal stents. Further, for airway
stenting, reconstructed CT images are very useful for measuring the distance between the fistula and a carina or vocal cord, in the determination optimal stent length.
References:
4. Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 2008;34:1103-1107
5. Shin JH, Song HY, Ko GY, Lim JO, Yoon HK, Sung KB. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology 2004;232:252-259
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