title: Non-malignant respiratory tract fistula from the oesophagus. A lethal condition for which novel therapeutic options are emerging.
abstract: OBJECTIVE
  Fistulas between the oesophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after oesophageal resection, without any signs of local residual tumour growth. Other causes that are, by definition, benign may rarely prevail. The traditional therapeutic approach is to divert the proximal portion of the oesophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. We have evaluated our stent-based strategy for managing these life-threatening situations.
  
  
  METHODS
  At Karolinska University Hospital, all patients admitted with an oesophago-respiratory fistula during the period 2003-2011 followed a stent-based strategy. On clinical suspicion, a prompt computed tomography scan was performed with contrast ingestion, to visualize the status of the anastomosis and the potential communications. Often an endoscopy was done to assess the oesophagus and the conduit. The respiratory tree was inspected through a concomitant bronchoscopy. The double-stent strategy presently applied meant that covered self-expandable metal stents (SEMS) were applied on the alimentary and airway sides to adequately cover the fistula orifice on both sides. The subsequent clinical course determined the ensuing therapeutic strategy.
  
  
  RESULTS
  During the study period, 17 cases with oesophago-respiratory fistulas were treated at our unit, of which 13 exhibited fistulation following an oesophageal resection due to cancer and 4 cases had a benign underlying disease. The cancer patients did not show any obvious demographic profile when it came to the cancer sub-location, histological type of cancer, or treatment with neoadjuvant chemo- and radiochemotherapy. There was an equal distribution between hand-sutured and stapled anastomoses. In 10 of the cases, the anastomoses were located in the upper right chest; the remainder in the neck, and all reconstructions were carried out by a tubulized stomach. The diagnosis of the fistula tract between the anastomotic area and the respiratory tract was attained on the 15th postoperative day (median), with a range from 5 to 24 days.
  
  
  CONCLUSIONS
  When an oesophago-respiratory fistula is diagnosed, even in a situation where no neoplastic tissue is prevailing, attempts should be made to close the fistula tract by SEMS from both directions, i.e. from the oesophageal as well as the respiratory side. By this means, a majority of these patients can be initially managed conservatively with prospects of a successful outcome, although virtually all will eventually require a single-stage resection and reconstruction.
authors.affiliation: Division of Surgery, CLINTEC, Karolinska Institute, Sweden. peter.elbe@karolinska.se
authors.forename: Peter
authors.initials: P
authors.lastname: Elbe
authors.forename: Mats
authors.initials: M
authors.lastname: Lindblad
authors.forename: Jon
authors.initials: J
authors.lastname: Tsai
authors.forename: Jan-Erik
authors.initials: JE
authors.lastname: Juto
authors.forename: Gert
authors.initials: G
authors.lastname: Henriksson
authors.forename: Thorhallur
authors.initials: T
authors.lastname: Agustsson
authors.forename: Lars
authors.initials: L
authors.lastname: Lundell
authors.forename: Magnus
authors.initials: M
authors.lastname: Nilsson
mesh_terms: D000328:Adult; D000368:Aged; D001999:Bronchoscopy / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D003287:Contrast Media; D004937:Esophageal Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D004945:Esophagoscopy / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008670:Metals; D008875:Middle Aged; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D016156:Respiratory Tract Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D015607:Stents; D013548:Sweden; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D003287:Contrast Media; D008670:Metals