D E Low1, R A Kozarek. 1. Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington 98111, USA.
Abstract
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.
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.