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Ann Thorac Surg 1998;65:923
© 1998 The Society of Thoracic Surgeons

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Commentary

^a Division of Cardiothoracic Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425-2279, USA

Invited commentary

Palliation of malignant esophagorespiratory fistulas requires a quick and effective method because survival is usually measured in weeks. Although esophageal bypass is an attractive possibility, in fact it is rarely an option because of the poor performance status of the patient and its attendant mortality and morbidity. As documented in this article by Drs Low and Kozarek, the most frequently used option is a stent to occlude the fistula and relieve dysphagia.

The development of self-expanding metallic stents (SEMS) has been greeted with enthusiasm because of the potential for fewer complications and improved ease of technical placement when compared with plastic prostheses. In our institution’s experience with SEMS for esphagorespiratory fistulas, the clinical success rate was 82% for the nitinol Ultraflex stent (Microvasive, Watertown, MA) and 86% for the Wallstent (Schneider, Minneapolis, MN) [1]. As verified by other series, our early complication rate was low (6%).

The finding of equivalent dysphagia relief with the differing stents by Low and Kozarek is somewhat surprising because the plastic stents only allow a semisolid diet and SEMS expand to 54F, with all series reporting excellent dysphagia relief. The key issue regarding the comparison of plastic prostheses and self-expanding metal stents is the accurate record of early morbidity, late complications, and, equally important, the reintervention rate. Our experience confirms the observations of Low and Kozarek, with a late complication rate of 18% and reintervention rate of 35% in a series of 14 patients undergoing SEMS placement for esophagorespiratory fistulas [1].

A large, prospective, randomized trial of plastic stent versus SEMS for both obstructive esophageal cancers as well as esophagorespiratory fistulas is needed to assess the palliative value of SEMS. Critical to this evaluation is an agreed-upon definition and accurate record of early complications, late complications, and reinterventions. An early comparison of the Wilson-Cook prosthesis (Winston-Salem, NC) and SEMS revealed fewer complications of SEMS, which offset the increased cost [2]. Only a large, controlled trial will answer the question of whether the number and type of complications in comparison with cost will favor the continued enthusiasm for expandable metal stents.

References

1. Mishra G., Hoffman B., Hawes R., Reed C., Portwood G. Self-expanding metallic stents (SEMS) for esophagorespiratory fistulas (ERF): technical success, efficacy, and complications [Abstract]. Gastrointest Endosc 1997;45:AB75.
2. Knyrim K., Wagner H.-J., Bethge N., Keymling M., Vakil N. 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]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carolyn E. Reed Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Reed, C. E. Search for Related Content PubMed Articles by Reed, C. E.