The classification and treatment strategies of post-esophagectomy airway-gastric fistula

Abstract

Background: Airway-gastric fistulas (AGFs) are rare but life-threatening complications after esophagectomy for esophageal cancer. Their effective and reasonable management is challenging and still controversial. This study reports the classification and management strategies of post-esophagectomy AGF based on a retrospective analysis of 26 cases in two large volume centers in China. Methods: Between January 2000 and December 2017, 6,316 consecutive patients with esophageal carcinoma underwent esophagectomy. AGF was verified in 26 patients. The patients with AGF were divided into two types based on the anatomic characteristics of the fistula. Type I was characterized by the presence of fistula orifices in digestive tract that were higher than those in the airway and were treated with conservative management. Type II had both fistula orifices located on the same horizontal plane and were treated with surgical management. Pearson Chi-Square (R software) was used to compare mortality rates. Results: From January 2000 and December 2017, 26 cases occurred AGF in 6,316 consecutive patients with esophageal carcinoma underwent esophagectomy and the incidence of AGF was 0.4%. Ten of 12 patients with type I AGF survived. Nine of 14 patients with type II AGF died. There was a significantly difference in the mortality rates between patients with AGF type I and II, which was 16.7% (2/12) and 64.3% (9/14) (χ 2 =6.003, P=0.014), respectively. Conclusions: AGF may be classified into two types according to the anatomic characteristics. Type I patients may be cured by conservative management and type II patients, require surgical intervention with pedicled tissues flap wrapping of the airway.

Management of Esophageal Cancer-Associated Respiratory–Digestive Tract Fistulas

“…However, symptom control is the best prognostic factor for long-term survival [ 29 ]. The key principle of the RDF treatment strategies must be airway protection to reach patient stabilization and reduce infectious complications [ 33 , 34 ].…”

“…The literature emphasizes the value of esophageal stenting for RDF therapy: initial symptom control rates of up to 90% have been published [ 3 , 5 , 6 , 18 , 23 , 26 , 29 ], although fistula recurrence is frequent six weeks after stent placement [ 26 , 33 ]. Our data align with these results: 68% of stents were not associated with symptom control, but esophageal stent placement improved mean survival to 11.9 ± 6.5 months in T-RDF patients, which corresponds approximately to the 1.5–5-fold survival in the literature [ 15 , 26 , 28 , 29 ].…”

“…In well-selected patients, surgical intervention has resulted in significantly longer survival of 10–105.0 months [ 15 , 30 , 31 ]. For surgery-associated RDF (S-RDF), overall mortality has been reported to range between 25.0 and 57.1%, with inconsistent results regarding surgical (17.4–100.0%) and non-surgical (25.0–28.3%) outcome [ 18 , 32 , 33 ].…”

Three-step operation for esophago-left bronchial fistula with respiratory failure after esophagectomy: a case report with literature review

“…Most of case series on EBF after esophagestomy are from late 1990s onward, and it is a very rare complication with an incidence of 0.26–3.15% [ 4 – 15 ]. EBF is one of the most difficult complications to deal with after esophagectomy and reconstruction via a gastric tube thorough the posterior mediastinal route.…”

“…Shen et al [ 7 ] described that single-stage primary repair of tracheoesophageal fistula with tissue flap interposition can safely be performed successfully in the majority of patient. On the other hand, some reports classify fistula according to type and location, and suggest that the indications for surgery should be carefully determined [ 10 , 15 ]. The interposed vital tissue used for repair are similarly varied, with latissimus dorsi muscle flap, major pectoral muscle flap, pericardial flap and pedicled muscle flap being reported [ 12 , 17 ].…”