The clinical characteristics, treatments and prognosis of post-esophagectomy airway fistula: a multicenter cohort study

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Abstract

Background

Post-esophagectomy airway fistula (PEAF) is a serious complication after esophageal cancer resection. At present, the clinical characteristics, treatments and prognosis of PEAF patients remain inconclusive. We aimed to investigate these problems of patients with PEAF through a multi-center retrospective cohort study.

Methods

We included consecutive patients who underwent esophagectomy for esophageal cancer in seven major Chinese esophageal cancer centers from January 2010 to December 2020. Based on the anatomic characteristics of PEAF patients, PEAFs were divided into Union type I (without digestive fistula) and Union type II [respiratory-digestive fistula (RDF)], and subtypes a and b (tracheal or bronchial fistulas), as well as L1 and L2 (same or different level of fistulas). The clinical characteristics, diagnoses, managements, and effects of the various types were retrospectively analyzed.

Results

PEAF occurred in 85 of 26,608 patients (0.32%), including eight females and 77 males. There were 16 patients with type I and 69 with type II. The numbers of healings, non-healings, and deaths at discharge were 45 (52.9%), 20 (23.5%), and 20 (23.5%), respectively. Type Ib was common in type I, and type II L1 was common in type II. The healing rates of surgical, stent, and conservative treatments were 50%, 60%, and 50%, respectively. All type I patients treated with stent implantation were healed at discharge. The healing rates, mortality, and 3-year survival of type II L1 and type II L2 patients were 55.4% and 30.8%, 17.9% and 30.8%, and 34.3% and 15.4%, respectively. The 5-year survival rates of all PEAFs were 21.1%.

Conclusions

PEAF is an infrequent and life-threatening complication after esophagectomy. Patients with different types of PEAF often have different inducements. In this study, we found that the healing rates of surgical and conservative treatments were similar, and stent implantation may have the potential to improve efficacy. Type II L2 patients were the most difficult to cure.

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Most cited references 28

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Tracheoesophageal fistula.

Michael Reed, Douglas Mathisen (2003)

Acquired TEF is a rare complication that can occur from a variety of causes. The most common etiology of nonmalignant TEF is as a complication of intubation with cuff-related tracheal injury. Most patients present with increased secretions, pneumonia, and evidence of aspiration of gastric contents while the patient is on mechanical ventilation. When diagnosed after extubation, the most frequent sign of TEF is coughing after swallowing. A high index of suspicion is required in patients at risk for developing a TEF. The diagnostic evaluation is by bronchoscopy and esophagoscopy. When the diagnosis has been made, the immediate goal should be to minimize tracheobronchial soilage by placing the cuff of a tracheostomy tube distal to the fistula. Reflux of gastric contents is diminished by placement of a gastrostomy tube, and adequate nutrition is facilitated by inserting a jejunostomy tube. Surgical correction is required because spontaneous closure is rare, but surgery should be postponed until the patient is weaned from mechanical ventilation because positive pressure ventilation after tracheal repair carries an increased risk of anastomotic dehiscence and restenosis. An anterior cervical collar incision can be used for most cases of post-intubation TEFs. The esophagus should be closed in two layers over a nasogastric tube and buttressed with a pedicled strap muscle flap. If the tracheal defect is small, primary repair can be employed. In most cases, however, the best results can be achieved with tracheal resection and reconstruction. The patient should be extubated at the completion of the case, if possible. With this strategy, as first described by Grillo and colleagues [27], single-stage repair can be performed safely and with a high success rate. Malignant TEFs cannot be cured because of the underlying incurable disease process. As with nonmalignant TEFs, the principal complications are tracheo-bronchial contamination and poor nutrition. Without prompt palliation, death occurs rapidly, with a mean survival time of between 1 and 6 weeks in patients who are treated with supportive care alone. The most common primary tumor causing malignant TEF is esophageal carcinoma. The other frequent cause is lung cancer. Patients present with signs and symptoms typical of TEF, including coughing after swallowing. Diagnosis is made by barium esophagography, and the location and size of the fistula is determined by bronchoscopy and esophagoscopy. Treatment must correct the two problems of airway contamination and poor nutrition. The most effective treatments are esophageal bypass and esophageal stenting. Bypass is demonstrated to resolve respiratory soilage and allow fairly normal swallowing, but it should be reserved for patients who can tolerate a major operation. Stenting can be offered to nearly all patients regardless of their physiologic condition. Stenting also limits aspiration and allows swallowing. Esophageal exclusion is rarely indicated in the current era of familiarity with stenting techniques. Direct fistula closure and fistula resection do not yield satisfactory results. Radiation therapy and chemotherapy combined might offer a survival benefit compared with supportive care alone. The complication of TEF secondary to malignancy is a devastating problem that carries a bleak prognosis, but when it is performed promptly after the diagnosis of a malignant TEF, esophageal bypass or stenting improves survival and quality of life for these unfortunate patients.

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Surgical management of acquired nonmalignant tracheoesophageal and bronchoesophageal fistulae.

Mark S. Allen, Francis Nichols, Claude Deschamps … (2010)

Acquired nonmalignant fistulae between the airway and esophagus (tracheoesophageal fistulae [TEF]) are rare life-threatening conditions. Several management approaches have been proposed, while the optimal strategy remains controversial.

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Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy.

Christianne J. Buskens, Jan B.F. Hulscher, Paul Fockens … (2001)

Benign tracheo-neo-esophageal fistulas after esophagectomy are rare and treatment can be challenging. They can result from perioperative tracheal injury or various postoperative complications. Charts of 6 patients with a benign tracheoneo-esophageal fistula after subtotal esophagectomy treated in this institution between July 1993 and August 1999 were analyzed. Three men and 3 women (median age 61 years) developed a fistula after subtotal esophagectomy. Symptoms varied from mild swallowing difficulties to aspiration pneumonia and mediastinitis. Two patients with mild symptoms were treated conservatively. In 1 patient a long fistula was partly excised through the neck. In 3 patients the gastric tube was excluded or excised, with surgical closure of the tracheal defect. The alimentary tract was reconstructed by colonic interposition. There were no major complications. After a median follow-up of 1.6 years, all fistulas were closed. All patients were capable of sufficient oral intake. A benign tracheo-neo-esophageal fistula after esophagectomy is a rare, but serious complication. Site and size of the fistula, together with the severity of symptoms, should dictate management.

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Author and article information

Journal

Journal ID (nlm-ta): Transl Lung Cancer Res

Journal ID (iso-abbrev): Transl Lung Cancer Res

Journal ID (publisher-id): TLCR

Title: Translational Lung Cancer Research

Publisher: AME Publishing Company

ISSN (Print): 2218-6751

ISSN (Electronic): 2226-4477

Publication date (Print and electronic): March 2022

Publication date (Print): March 2022

Volume: 11

Issue: 3

Pages: 331-341

Affiliations

[1 ]Fujian Key Laboratory of Cardiothoracic Surgery (Fujian Medical University) , Fuzhou, China;

[2 ]deptDepartment of Thoracic Surgery , Fujian Medical University Union Hospital , Fuzhou, China;

[3 ]deptDepartment of Thoracic Surgery, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine , Sun Yat-sen University Cancer Center , Guangzhou, China;

[4 ]deptDivision of Thoracic Surgery, Sichuan Cancer Hospital & Research Institute, School of Medicine , University of Electronic Science and Technology of China (UESTC) , Chengdu, China;

[5 ]deptDepartment of Thoracic Surgery, West China Hospital , Sichuan University , Chengdu, China;

[6 ]deptKey Laboratory of Carcinogenesis and Translational Research (Ministry of Education), the First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute , Peking University School of Oncology , Beijing, China;

[7 ]deptDepartment of Thoracic Surgery, Shanghai Chest Hospital , Shanghai Jiao Tong University , Shanghai, China;

[8 ]deptDepartment of Thoracic Surgery , The Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital , Zhengzhou, China;

[9 ]Division of Pulmonary Critical Care, Department of Medicine, Interventional Pulmonology Section, Westchester Medical Center, New York Medical College, Valhalla , NY, USA,

Author notes

Contributions: (I) Conception and design: B Zheng, T Zeng, C Chen; (II) Administrative support: C Chen; (III) Provision of study materials or patients: B Zheng, H Yang, X Leng, Y Yuan, L Dai, X Guo, Y Zheng; (IV) Collection and assembly of data: B Zheng, T Zeng; (V) Data analysis and interpretation: B Zheng, T Zeng; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

[#]

The authors contributed equally to this work and should be considered as co-first authors.

Correspondence to: Chun Chen, MD. Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29, Xinquan Road, Fuzhou 350001, China. Email: chenchun0209@ 123456fjmu.edu.cn .

Article

Publisher ID: tlcr-11-03-331

DOI: 10.21037/tlcr-22-141

PMC ID: 8988080

PubMed ID: 35399570

SO-VID: 2cc5f00a-bde7-4c48-9729-ba4448943737

License:

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0.

The clinical characteristics, treatments and prognosis of post-esophagectomy airway fistula: a multicenter cohort study

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Abstract

Background

Methods

Results

Conclusions

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ScienceOpen Clinical Case Reports Collection

Most cited references 28

Tracheoesophageal fistula.

Surgical management of acquired nonmalignant tracheoesophageal and bronchoesophageal fistulae.

Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy.

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