Ann Thorac Surg 1997;64:355-358
© 1997 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Management of Malignant Tracheoesophageal Fistulas With a Cuffed Funnel Tube
Lajos Kotsis, MD, PhD,
Kornélia Zubovits, MD,
Pál Vadász, MD, PhD
Thoracic Surgical Clinic of Korányi National Institute for Pulmonology and Postgraduate Medical School, Budapest, Hungary
Accepted for publication February 17, 1997.
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Abstract
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Background. A detachable cuffed flange tube for the assessment of malignant tracheoesophageal fistulas by a minimal invasive surgical insertion technique is presented. The funnel cuff of this tube seals the space between the esophageal wall and the flange of conventional tubes above the fistula at the level of the suprastrictural dilatation.
Methods. Twenty-eight patients having a malignant esophagorespiratory fistula with associated primary or secondary esophageal stricture, except 1, underwent esophageal intubation with this prosthesis between 1983 and 1996.
Results. All insertion attempts, without previous esophageal dilation, were successful. The overall mortality was 7.4%. The cuffed funnel has provided hermetic watertight exclusion of the fistula in all instances. Intraabdominal septic complications, reflux, or tube displacement have never occurred after use of this intubation technique.
Conclusions. For occlusion of malignant respiratory tract fistulas this cuffed flange tube proved to be superior to conventional esophageal prostheses.
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Introduction
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The therapeutic problem created by a malignant fistula between the esophagus and the airway is one of the most challenging conditions in thoracic surgery. Because its victims are frequently wasted and have limited pulmonary reserves, the theoretically ideal operation of one-stage fistula exclusion and esophageal bypass is seldom accomplished [1–3]. Treatment by esophageal intubation offers much less operative risk, but this procedure has its own complications, notably leakage around the prosthesis and massive gastroesophageal reflux through the stented esophagogastric junction [4–6].
To increase the effectiveness of this procedure, in 1983 the first author (Dr Kotsis) designed a two component, detachable tube having a cuffed funnel for watertight obliteration of these fistulas [7]. The tube is basically a two-component pull-through tube. The entire apparatus is constructed with easily available parts. The proximal end of the upper prosthetic section is soft and flared (the better to conform to the irregular lumen of the esophagus). As a consequence of the tube preparation, the prosthesis remains entirely in the esophagus and the antireflux mechanism of the esophagogastric junction functions normally. The aim of this study was to evaluate the outcome of 28 patients with malignant airway fistulas treated since 1983 with such a tube.
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Material and Methods
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Since 1982, 204 patients with inoperable malignant esophageal obstruction underwent intubation using a personally designed prosthesis. Twenty-eight of these patients had a fistula in the airway: in 16 patients the fistula communicated with the bronchus and in 5 with the trachea. The remainder were complicated fistulas involving the lung parenchyma mediastinum, trachea and bronchus together, or all of these.
The male-to-female ratio was 8:1. Four patients had undergone previous irradiation or chemotherapy. Three patients had florid pulmonary infection and one of these had superior vena cava syndrome. All patients received parenteral nutrition, along with metronidsole cephalosporin and tobramycin for 3 to 7 days before intubation.
The prosthesis was constructed from a previously prepared segment of Tygon tubing having an external diameter of 15 to 17 mm. In 15 instances conventional tubes (Celestin, Procter-Livingston, or Wilson-Cook) were used. Its length was determined by measurements of the growth using esophagography and, in each instance, was sufficient to bridge the interval from the upper end of the malignant stricture to a level just above the cardia. The proximal end of the Tygon tubes had been heated and flared to a 45-degree funnel. Adhesive was applied to the outside surface of this funnel and over this was fixed a 1-cm-thick plastic sponge collar (Fig 1
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Fig 1. . Components of a tube for complete occlusion of malignant tracheoesophageal fistulas: the proximal part with its flange cuffed by plastic sponge layer, and the distal, detachable segment with inside traction sutures.
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The distal end of the Tygon prosthesis was "fishmouthed" by cutting two V-shaped notches opposite each other. An 80-cm-long, no. 2 USP Synthofil suture was then stitched through the base of each of the two "tongues." The four resulting suture ends were threaded through the lumen of a 25-cm-long urologic Nelaton catheter (no. 24) segment in such a manner that the tongued end of the Tygon tube could be firmly pulled into the wide end of the Nelaton catheter segment. A hemostat clamp was applied across the lower end of this catheter to maintain tension on it. In this way four inside sutures were obtained at the lower end of this intermediate tube segment.
Through a short (4 cm) upper midline laparotomy and a point-like gastrostomy under general anesthesia, a Celestin tube guide (or a no. 6 ureteral catheter) and then with its help a duodenal suction catheter were passed beyond the tumor in an either antegrade (through the mouth) or retrograde manner. In either event the oral end of the traction catheter was then tied to the four previously described inside sutures at the end of the intermediate Nelaton catheter segment.
Traction was then applied to the gastric end of the traction catheter until the Tygon prosthesis was seated (Fig 2). Probing with the index finger outside the esophagogastric junction verified that the distal tip of the prosthesis lay above the level of the hiatus. At last the composite tube was extragastrically detached from the traction catheter by cutting the sutures between the intermediate tube part and traction catheter. Then the detached Nelaton catheter segment and the inside sutures were withdrawn from below. Thus the tube remained only in the esophagus, above the cardia (Fig 3), in a reflux-free situation. The stomach and abdominal wounds were closed in standard fashion.
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Fig 2. . Illustration of intubation with the two-component ( A, C) detachable tube with cuffed funnel by our minimally invasive traction technique. After insertion of this tube the distal part (C) is cut off (B) from the traction catheter (e) extraabdominally and removed with inner traction sutures, stitched through the V-shaped cut end of the basic tube ( A). (a = suprastrictural dilatation; b = tube flange with plastic sponge collar; c = secondary stricture by inoperable bronchial tumor; d = gastrostomy.)
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Fig 3. . After removal of the distal tube part (Nelaton catheter segment) the basic tube ( A) remains only in the esophagus, above the cardia (D).
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Results
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No esophageal dilation was needed beyond that furnished by passing the Tygon stent. We saw no iatrogenic perforations either from passing the guide lead or seating the prosthesis. A Gastrografin (Schering AG, Berlin, Germany) swallow on the first postoperative day confirmed watertight exclusion of the fistulas and a reflux-free situation in each instance (Figs 4–6). There was no sepsis and no late tube dislodgement. All patients were relieved of fistula symptoms and were able to eat a soft diet for the remainder of their lives (2 to 6 months). The 30-day mortality was 7.4%.
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Fig 4. . (A) Left malignant esophagobronchial fistula with associated esophageal stricture and (B) its watertight occlusion with our cuffed flange tube.
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Fig 5. . (A) Malignant esophagotracheal fistula with a secondary esophageal obstruction of a patient having a superior vena cava syndrome too and (B) the postoperative aspect after insertion of our tube.
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Fig 6. . (A) Right esophagomediastinobronchial fistula and (B) the postoperative finding after cuffed flange tube insertion.
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Comment
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Only a small group of patients with tracheoesophageal fistulas are able to tolerate a major surgical procedure such as surgical exclusion with gastric [3], jejunal [8], or colonic [2] bypass. Despite the technical improvements of the Kirschner operation [9] and of cervical esophagogastrostomy [10, 11], the incidence of fistula formation at this level remains high [3]. Angorn [4] reported a 25% mortality and effective tamponade of malignant fistulas in 75% of 184 cases of pulsion intubation with a Procter-Livingston tube. Although endoscopic placement of a large Montgomery salivary stent [12] was useful, even in the case of fistulas without accompanying esophageal stricture, the operative mortality was high (36.6%). Most authors [4–6, 13] observed that successfully inserted prostheses may allow diversion of food and liquids past the fistula. An incidence of 5% to 10% of esophageal perforation can be expected from esophageal dilation [14–16], which is a prerequisite of the endoscopic pulsion procedures. In instances of secondary esophageal strictures, the rate of this complication may be doubled [17].
Our traction-insertion modification obviates the need for preliminary dilation because the sharpened end of the Tygon tube, once inserted firmly in the appropriate end of the Nelaton catheter segment itself, stretches the esophagus for a snug fit. The watertight closure of the fistula [7] is partly attributed to the snug fit of the tube and especially to the tamponade provided by its uppermost cuffed flange. Insertion of the funnel exactly into the dilated esophagus above the fistula is an essential detail of the technique. The cuffed flange may have also produced an antidislodgement effect, as there was no tube dislodgement in our series.
This tube can provide successful palliation (Table 1) in high supraaortic fistulas, or in instances of esophageal tortuosity or deviation, circumstances when efforts to insert a Wilson-Cook esophageal balloon prosthesis would have been dangerous or impossible. Another special use for our tube is after an unsuccessful attempt at endoscopic intubation [17].
The principal contraindications to intubation are stenosing invasion of the tracheal bifurcation or main bronchus, superior vena cava syndrome, or cardiac arrhythmias. Postoperative complications attendant to the usual pull-through procedures (gastric suture line leakage, intraabdominal infection, tube migration, and aspiration [1, 4] were not seen.
The patient with a malignant esophageal tumor and fistula to the airway may appear wasted, but most can usually survive what is mainly an extraabdominal operation. The operation we have described is a limited invasive surgical technique and has a low morbidity and mortality with functional results and mortality that compare favorably with closed methods of endoscopic intubation.
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Acknowledgments
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We thank Clement A. Hiebert, MD, from the Editorial Board for his contribution to this article.
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Footnotes
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Address reprint requests to Dr Kotsis, H-1529 Budapest, Pihenö út 1, Hungary.
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References
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Abstract
Introduction
