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Ann Thorac Surg 1995;60:199-200
© 1995 The Society of Thoracic Surgeons

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Case Reports

Role of Covered Esophageal Stents in Malignant Esophagorespiratory Fistula

Department of Thoracic Surgery, Royal Brompton Hospital, London, England

Accepted for publication December 7, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Comment References

 
Malignant esophagorespiratory fistulas are distressing for patients who already have a limited prognosis. Palliative treatment by surgical bypass is often unjustified, and although the use of esophageal stents is more appropriate, their results are variable due to their inability to provide a tight seal. We have managed 2 patients with self-expanding covered esophageal stents, which appear to offer excellent prospects for palliation.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Comment References

 
Esophagorespiratory fistulas may result from locally advanced esophageal or tracheobronchial malignancies or as a complication of treatment, particularly radiotherapy or esophageal dilation and stenting. Management of these patients is difficult as they are generally debilitated and have a limited life expectancy, making a major surgical procedure unjustified. Palliation by insertion of conventional (Atkinson, Celestin) esophageal stents is an alternative, but results of this are variable [1–3]. We describe the use of a self-expanding covered esophageal stent in the treatment of this problem.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Comment References

 
Prosthesis and Technique of Insertion
The Gianturco-Rösch covered esophageal stent (Cook Inc, Bloomington, IN) is a self-expanding metallic stent made of stainless steel wire constructed in a cylindrical zigzag configuration and covered with polyethylene (Fig 1). It has a flange at either end with a diameter of 25 mm and a mid-diameter of 18 mm with ``hooks'' in its midportion.

View larger version (54K): [in this window] [in a new window]   Fig 1. . Gianturco-Rösch covered esophageal stent.

Case Reports
PATIENT 1.
A 71-year-old man was admitted with a 2-month history of hemoptysis and a month's history of odynophagia. Fiberoptic bronchoscopy revealed an extensive posterior tracheobronchial tumor with significant obstruction of the left main bronchus. A barium swallow showed a 3-cm irregular esophageal narrowing below the level of the carina with a small fistula communicating with the intermediate bronchus. At operation, diathermy resection was performed to relieve the left main bronchial stenosis, and a 10-cm covered esophageal stent was inserted. Esophageal and bronchial biopsy specimens taken at the time confirmed a squamous cell carcinoma. The patient was able to swallow solid food over the ensuing days and underwent radiotherapy. His swallowing remains satisfactory 2 months later.

PATIENT 2.
A 73-year-old woman presented with hemoptysis, dyspnea, and dysphagia. She had postcricoid squamous carcinoma treated by radiotherapy and pharyngolaryngectomy 3 years ago. A postirradiation tracheoesophageal fistula had developed, which was repaired with a muscle flap. On admission, there were signs of mediastinal recurrence on computed tomography. Rigid bronchoscopy revealed extrinsic compression at the right main bronchus and diffuse narrowing of both main bronchi by intramural tumor plaques, which were most likely the cause of her hemoptysis. Esophagoscopy showed a tight stricture at 25 to 30 cm, and bougienage was performed with ease. Biopsy specimens from the bronchus and esophagus revealed infiltration by poorly differentiated squamous cell carcinoma. Her swallowing improved, but a week later she re-presented with symptoms of an esophagorespiratory fistula, which was confirmed on barium swallow. Under general anesthesia, a 10-cm covered esophageal stent was inserted. She was able to swallow without aspirating over the next few days and underwent further radiotherapy, but died a month later of hemoptysis.

	Comment

Top Footnotes Abstract Introduction Material and Methods Comment References

 
The results of treatment of malignant esophagorespiratory fistulas are often disappointing, with a reported 30-day mortality of 46% with most deaths (82%) resulting from persistent pulmonary sepsis despite the use of different treatment modalities [1].

Esophageal bypass provides the best palliation with improved survival in those fit to undergo a major operation [1]. In debilitated patients and those with extensive disease the insertion of esophageal stents is an attractive option, although results of conventional plastic endoprostheses have been poor [1, 2]. Recurrent respiratory contamination may occur from inability to seal the fistula proximally or as a result of stent migration. In addition, the use of plastic endoprostheses may result in complications including perforation, stent migration, hemorrhage, and obstruction [3].

A recent development in this field has been self-expanding esophageal metallic stents, which have the advantage of a lower incidence of complications than that of plastic endoprostheses (0% versus 43%, respectively) [4]. To prevent tumor ingrowth a further modification of the metallic stent has been the introduction of a polyethylene cover around the stent, which makes it theoretically suitable for treating esophagorespiratory fistulas. There has, however, been limited experience in this setting [5].

There are several features in the design of the covered stent that make it ideal for treating esophagorespiratory fistulas. Its self-expanding nature allows its covered surface to form a tight seal at the site of the fistula. The larger proximal and distal flange and ``anchoring hooks'' in its midportion help to prevent stent migration, which may be a cause of recurrent pulmonary soiling. Furthermore, these stents are initially compressed and delivered through very small catheters. They do not require extensive prestenting bougienage in comparison with pulsion devices (Atkinson tube), which would be more hazardous and have a higher risk of perforation or enlarging the fistula.

We have found the use of these stents to be uncomplicated and safe. The fluoroscopic times for both cases were less than 5 minutes. Both patients experienced immediate relief and were able to swallow soon after. Our early experience with the Gianturco-Rösch covered esophageal stent is encouraging. It would appear to offer excellent prospects for palliating malignant esophagorespiratory fistulas and deserves further evaluation.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Comment References

 
Address reprint requests to Mr Goldstraw, Department of Thoracic Surgery, Royal Brompton Hospital, Sydney St, London SW3 6NP, England.

	References

Top Footnotes Abstract Introduction Material and Methods Comment References

 

1. Burt M, Diehl W, Martini N, et al. Malignant esophagorespiratory fistula: management options and survival. Ann Thorac Surg 1991;52:1222–9.[Abstract]
2. Hegarty MM, Angorn IB, Bryer JV, Henderson BJ, Le Roux BT, Logan A. Palliation of malignant esophago-respiratory fistulae by permanent indwelling prosthetic tube. Ann Surg 1977;185:88–91.[Medline]
3. Cusumano A, Ruol A, Segalin A, et al. Push through intubation: effective palliation in 409 patients with cancer of the esophagus and cardia. Ann Thorac Surg 1992;53:1010–4.[Abstract]
4. Knyrim K, Wagner H-J, Bethge N, Keymling M, Vakil N. A controlled trial of an expandable stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329:1302–7.[Abstract/Free Full Text]
5. Wu WC, Katon RM, Saxon RR, et al. Silicone-covered self expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature. Gastrointest Endosc 1994;40:22–33.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kit Wong Peter Goldstraw Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wong, K. Articles by Goldstraw, P. Search for Related Content PubMed PubMed Citation Articles by Wong, K. Articles by Goldstraw, P.