Ann Thorac Surg 1998;65:919-923
© 1998 The Society of Thoracic Surgeons
Comparison of Conventional and Wire Mesh Expandable Prostheses and Surgical Bypass in Patients With Malignant Esophagorespiratory Fistulas
Donald E. Low, MDa,b,
Richard A. Kozarek, MDa,b
a Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington, USA
b Section of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
Accepted for publication October 27, 1997.
Address reprint requests to Dr Low, Department of General Surgery, Virginia Mason Medical Center, PO Box 900 (C6-GSUR), Seattle, WA 98111
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Abstract
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Background. Patients who present with malignant esophagorespiratory fistula continue to provide a significant palliative challenge to gastroenterologists and surgeons.
Methods. This retrospective series reviewed 29 patients treated with conventional prostheses (13 patients), expandable wire mesh-coated prostheses (12 patients), and surgical bypass with esophageal exclusion (4 patients) between 1982 and 1995.
Results. Improvement in dysphagia scores were comparable in all three groups. Fistula occlusion was more successful with expandable prostheses (92%) compared conventional prostheses (77%); however, reinterventions were required more commonly with expandable prostheses, which were also significantly more expensive on a unit cost basis. In selected patients in whom prosthesis placement either was inappropriate or failed, surgical bypass and esophageal exclusion was undertaken. These patients demonstrated good palliation with minimal morbidity and no mortality.
Conclusions. Both conventional and expandable prostheses are safe and reasonably straightforward treatment modalities for patients with esophagorespiratory fistulas. Because of ease of insertion and large luminal diameter, expandable metal prostheses will see increasing use in treatment of these difficult patients; however, conventional prostheses will remain a good alternative, especially in patients with extrinsic esophageal compression. When stent placement is either unsuccessful or inadvisable, physiologically fit patients can undergo surgical bypass and esophageal exclusion with good palliation and minimal morbidity and mortality.
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Introduction
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Historically, patients who present with malignant esophagorespiratory fistulas have had a poor prognosis and a high complication rate, which makes them difficult to palliate. Successful treatment of these patients should provide immediate fistula occlusion and the ability to reestablish oral intake in a timely and cost-efficient manner while minimizing the need for secondary medical interventions. These patients have a limited life expectancy based on the local and systemic extent of their malignancy; however, control of pulmonary contamination can provide the opportunity for secondary treatment as well as the opportunity for improved survival and quality of life. The development of coated expandable metal prostheses has provided a new palliative option in addition to standard conventional prostheses and surgical bypass.
This study is a retrospective review of patients undergoing therapy for malignant esophagorespiratory fistulas at Virginia Mason Medical Center. The three most commonly applied treatment modalities (ie, conventional prostheses, wire mesh expandable prostheses, and retrosternal surgical bypass with esophageal exclusion) are compared with respect to safety and treatment success.
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Material and methods
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Between 1982 and 1995, 29 patients with malignant esophagorespiratory fistulas presented to Virginia Mason Medical Center. Thirteen were treated with conventional prostheses, either Wilson-Cook prosthesis (Winston-Salem, NC) or Atkinson tube (Key Med, Inc, New Hyde Park, NY). Twelve patients were treated with expandable wire mesh prostheses, either a Wallstent (Schneider, Inc, Minneapolis, MI) or Z-Stent (Wilson Cook, Inc) (Fig 1). Four patients underwent retrosternal surgical bypass with esophageal exclusion, bypass being performed with either stomach or colon (Fig 2). These three patient groups were compared with respect to treatment efficacy (ie, fistula occlusion, ability to eat, complications, and survival).
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Fig 1. (A) Patient with esophageal malignancy and large esophagorespiratory fistula. (B) Same patient after complete occlusion of fistula with 6-cm Wallstent.
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Fig 2. (A) Patient with previous near-total esophagectomy for cancer in whom fistula developed secondary to mediastinal recurrence of cancer. (B) Same patient after retrosternal bypass with colon.
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Results
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Comparison of patient age, sex ratio, and cancer location and type are reviewed in Table 1. Mean age was comparable within the three groups, as was male-to-female ratio. Primary lung cancers were seen more commonly than esophageal or mediastinal malignancies in patients treated with prostheses. Squamous cell cancers were seen more commonly than adenocarcinoma, and except for the surgical bypass group, the majority of patients treated with esophageal stenting had received prior radiotherapy, chemotherapy, or both. The specific type of prosthesis or surgical conduit used is reviewed in Table 2. It should be noted that in both the Wallstent and Z-Stent patients, a subset had placement of prototype stents, the designs of which have been improved subsequently. All of the expandable wire mesh prostheses reported in this series, however, were silicone coated. Fistula occlusion was achieved in a high proportion of all patients (Table 3), 10 of 13 patients with conventional prostheses (77%), 11 of 12 with expandable metal prostheses (92%), and 4 of 4 with surgical bypass. Improvement in pre- versus posttreatment dysphagia scores were comparable in all three groups, although posttreatment interventions were less likely in patients undergoing surgical bypass (Table 3). Mean survival was 1.1 months in patients with conventional prostheses, 3.1 months in patients with expandable prostheses, and 6 months in patients with surgical bypass. Cost comparison of conventional versus expandable prostheses was a difference of $80 to $100 for conventional prostheses versus $1,000 to $1,900 for expandable prostheses.
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Fig 3. Surgical options for bypass of esophageal respiratory fistula: (A) retrosternal gastric tube with complete esophageal exclusion, (B) retrosternal colonic bypass of extensive esophagogastric tumor with proximal esophageal exclusion, and (C) retrosternal gastric tube with Roux-en-Y drainage of excluded esophagus (Kirschner operation) [11].
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Complications are reviewed in Table 4. Chest pain and aspiration pneumonia was seen more commonly with conventional prostheses; however, stent migration and delamination were more common with the expandable prostheses group. Restenting was more common with the expandable prostheses, usually related to patients who had significant extraluminal stent compression.
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Comment
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The treatment of patients with malignant esophagorespiratory fistulas has always been a major clinical challenge. The largest review currently in the literature by Burt and colleagues [1] demonstrates a median survival of 35 days in 207 patients presenting with esophagorespiratory fistulas. Patients who underwent supportive care alone survived a median of 22 days. The best survival was obtained in patients undergoing esophageal bypass procedures or radiation therapy alone. However, 17% of patients undergoing esophageal bypass with stomach survived more than 1 year.
The advent of expandable metal silicone-coated prostheses has been an important addition to our therapeutic armamentarium and multiple series have reported increased ease of insertion but no definitive improvement in survival rate [2–4].
Our experience suggests that both conventional and expandable prostheses have comparable rates of fistula occlusion and dysphagia palliation. Reinterventions were actually more common in the expandable prosthesis group. Although survival was prolonged (3.1 versus 1.1 months) with expandable prostheses, it did not reach statistical significance.
Weigert and colleagues [2] found expandable prostheses to be highly efficient at fistula occlusion and improving oral intake; however, they reported a procedural-related mortality of 12.5%, a 30-day mortality of 50%, and a mean survival of only 49 days.
Our institution has recently participated in a large multicenter trial comparing the treatment success of expandable wire mesh stents in patients with malignant dysphagia and tracheoesophageal fistula [5]. This involved nine university and referral centers treating 56 patients with malignant dysphagia, 11 of whom had coincidental esophagorespiratory fistulas. Successful fistula occlusion was achieved in 73% of patients; however, stent-related problems were noted in 22 of 54 (41%) of patients with expandable prostheses. Stent migration was reported in 15 (27% of all patients). Three of these patients required operation for a gastric or small bowel obstruction or perforation. Mean survival in all patients was reported as 51 days, although a subset of patients were still alive at time of publication.
It is clear that with increased ease of insertion and improved luminal diameter, expandable silicone-coated wire mesh prostheses will form the major treatment modality for patients with malignant esophagorespiratory fistulas. However, as our study points out, there is not a major difference in treatment success between conventional and wire mesh prostheses when inserted by experienced endoscopists. The only controlled trial comparing different types of prostheses was carried out by Knyrim and co-workers [4], who compared conventional and expandable prostheses in patients with dysphagia secondary to nonoperable malignancy, but not in patients with esophagorespiratory fistulas. They found no significant difference in the ability to place prostheses, posttreatment dysphagia or Karnofsky scores, incidence of postprocedural reinterventions, or 30-day or ultimate survival. They did note statistically significant differences favoring expandable prostheses when comparing time in hospital and complication rates. Incidence of both perforation and migration were significantly higher with conventional prostheses. They also identified a significant difference in cost to the patient when comparing conventional and expandable prostheses (conventional prosthesis being one-tenth the cost). However, they pointed out that this cost differential was negated by the fact that patients with expandable prostheses spent less time in hospital, even suggesting that a portion of the patients could be treated as outpatients.
Although it is clear that a majority of patients presenting with fistulas will be treated primarily with placement of endoscopic prostheses, centers that have access to experienced thoracic and esophageal surgeons have shown that in selected patients the best palliation and longest survival can be obtained with surgical bypass [1, 6, 7]. Previous series have reported procedural-related mortality rates in the range of 25% to 33% [1, 7]; however, these same series demonstrated that a significant portion of surgical patients will achieve excellent palliation from dysphagia with survival rates often exceeding 1 year. Our series demonstrates that selected patients can undergo esophageal bypass with exclusion without major morbidity or mortality, confirming previous reports by Akiyama and Hayama [8]. Obviously, these patients were selected on the basis of their physiologic fitness; however, postoperative complications were minimal (one anastomotic leak) and postoperative time in hospital was a mean of 12 days (range, 8 to 17 days). All patients were able to eat solid food after the operation, and 2 patients were able to return to work.
The hallmark of successful surgical bypass is leaving the esophagorespiratory fistula in place, but diverting oral intake retrosternally with either stomach or colon (Fig 3). The best bypass conduit is stomach; however, it is occasionally not available owing to the extent of tumor or previous operation. The ability to leave excluded esophageal segments in association with esophageal bypass is well documented in previous series [9, 10]; however, if the excluded esophageal segment is particularly long or if the mediastinal tumor is associated with infection or abscess formation, defunctioning the excluded segment with a Roux-en-Y segment of small bowel as described by Kirschner [11] is advised.
Although expandable wire mesh prostheses were successful at providing fistula occlusion and restoring oral intake in the majority of our patients, conventional prostheses appeared to provide a comparable initial level of fistula occlusion and ability to restore oral nutrition. Moreover, in the present series, their application was not associated with an increase in either complications or reintervention rates when compared with expandable mesh prostheses. They also offer a significant per unit advantage in cost. Expandable prostheses are easy to insert, effective, and in experienced hands relatively safe. However, conventional prostheses will continue to be an appropriate alternative in patients with malignant esophagorespiratory fistulas, especially those who have significant extraluminal obstruction. Surgical bypass in experienced hands will offer a good alternative in physiologically fit patients in whom previous stent placement has failed or is inappropriate due to tumor or anatomic factors. Patients undergoing operation in our series demonstrated prolonged survival with minimal morbidity. We currently believe that patients with malignant esophagorespiratory fistulas will receive optimal management in multispecialty centers with the expertise and experience to individualize a treatment approach in each patient.
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References
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- Burt M., Diehl W., Martini N., et al. Malignant esophagorespiratory fistula: management options and survival. Ann Thorac Surg 1991;52:1222-1229.[Abstract]
- Weigert N., Neuhaus H., Rosch T., et al. Treatment of esophagorespiratory fistulas with silicone-coated self-expanding metal stents. Gastrointest Endosc 1995;41:490-496.[Medline]
- Wu W.C., Katon R.M., Saxon R.R., 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]
- Knyrim K., Wagner J.H., Bethge N., et al. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329:1302-1307.[Abstract/Free Full Text]
- Kozarek R.A., Raltz S., Brugge W.R., et al. Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula. Gastrointest Endosc 1996;43:204-208.[Medline]
- Wong K., Goldstraw P. Role of covered esophageal stents in malignant esophagorespiratory fistula. Ann Thorac Surg 1995;60:199-200.[Abstract/Free Full Text]
- Weaver R.M., Matthews H.R. Palliation and survival in malignant oesophago-respiratory fistula. Br J Surg 1980;67:539-542.[Medline]
- Akiyama H., Hayama M. A simple esophageal bypass operation by the high gastric division. Surgery 1976;75:674-681.
- Mannell A., Epstein B. Exclusion of the oesophagus: is this a dangerous manoeuvre?. Br J Surg 1984;71:442-445.[Medline]
- Deaton W.R., Bradshaw H.H. The fate of an isolated segment of the esophagus. J Thorac Surg 1956;23:560-564.
- Kirschner M. Ein neves Verfahren der Oesophagoplatik. Arch Klin Chir 1920;114:606-663.
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Abstract
Introduction
