- Case report
- Open Access
Laparotomy enables retrograde dilatation and stent placement for malignant esophago-respiratory fistula
© Rehders et al; licensee BioMed Central Ltd. 2008
Received: 09 July 2007
Accepted: 26 January 2008
Published: 26 January 2008
Malignant esophageal stenosis with complete obstruction and esophagorespiratory fistula (ERF) is difficult to treat with standard endoscopic techniques.
We report a patient in whom with local recurrence of esophageal carcinoma an esophagotracheal fistula occurred. Initially the patient had undergone esophageal resection with interposition of a gastric tube. Due to complete obstruction of the lumen by recurrent tumor conventional transoral stent placement failed. For retrograde dilatation a laparotomy was performed. Via a duodenal incision endoscopic access to the gastric tube was achieved. Using a guidewire the esophageal obstruction was traversed and dilated. Then it was possible to place an esophageal stent via an antegrade approach.
Open surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.
Esophageal cancer is an aggressive tumor with unfavorable prognosis. Despite the radical surgery, local recurrence occurs in up to 21% of the cases . Dysphagias as well as esophago-respiratory fistulae (ERF) are predominant symptoms of local tumor recurrence and represent devastating and life threatening complications. Patients are often unable to swallow food or even their own saliva without aspiration. Unless sufficient palliation is instituted rapidly, the usual cause of death is pulmonary sepsis resulting from chronic aspiration. Since covered and self expandable stents have been introduced, successful palliation has been reported in most patients[2, 3]. The endoscopic management of malignant obstruction and ERF is technically challenging and requires careful endoscopic dilatation with wire guided dilators. Despite of sophisticated endoscopic strategies in some patients the passage of a guide wire is technically impossible due to a completely obstructed lumen. In this situation retrograde endoscopic dilatation via a radio guided percutaneous gastrostomy is a second option.
However in patients who underwent esophageal resection and transformation of the stomach into a small gastric tube for esophageal reconstruction, retrograde access is far more challenging, since not even radio guided procedures seem applicable. To our knowledge a suitable therapeutic approach in this difficult palliative situation has not been described before. We recently encountered a patient with local recurrence after esophageal resection and interposition of a gastric tube. Due to complete obstruction and ERF, he required a laparotomy for retrograde passage and subsequent stent placement.
Follow-up analyses revealed that the patient died 158 days after our treatment due to severe pleural effusion and diffuse pulmonary metastasis.
In patients with malignant esophageal obstruction and esophago-respiratory fistulae oral intake is limited by paroxysmal coughing, leading to profound malnutrition and death from recurrent pulmonary infections. Closure of the esophago-respiratory fistulae is the predominant goal of palliative therapy in this situation. Endoscopic placement of a covered expandable metallic stent is a well established minimal invasive approach . In most cases stent placement begins with a transoral passage of a guide wire through the esophageal stenosis. Sophisticated utilization of angiographic techniques with catheters and guide wires enables dilatation even of high grade esophageal stenoses.
However in cases with complete obstruction and associated fistulae stenoses often remain impassable, because the guide wire constantly enters the wrong lumen of the fistula. Recently a new technique with retrograde passage of the stenotic segment has been described [7, 8] and successfully applied in several centers [4, 9–11]. In all cases a percutaneous gastric puncture was performed and an endoscope was directed into the distal esophagus enabling retrograde dilatation. Unfortunately this technique does not apply to those patients who initially underwent esophageal resection and subsequent interposition of a gastric tube. In our view postoperative adhesions and adjacent loops as well as the location of the small residual stomach clearly impede percutaneous punction in these patients. Even radiologically guided techniques for percutaneous punction are extremely difficult and pose a high-risk of perforation. Therefore we performed open surgery, identified the duodenum and entered an endoscope through a spare longitudinal incision. Via the gastric tube a guide wire was pushed up and the esophageal obstruction was traversed for subsequent stent placement.
In patients with esophageal carcinoma local recurrence as well as ERF are frequently observed, despite of radical surgery and adjuvant radio-chemotherapy. If transoral passage and stent placement is not possible, these patients urgently need alternative approaches for successful palliation. Due to the interposition of a gastric tube, postoperative anatomy is complex and retrograde endoscopy via a percutaneous gastrostomy has not been described in the current literature.
In our view open surgery is a safe means to access the gastric tube via a duodenal incision, enabling retrograde endoscopic dilatation of the obstructed segment as well as simultaneous implantation of a jejunostomy catheter for sufficient enteral nutrition. This approach should be considered for high grade esophageal obstruction and ERF, when antegrade passage of the lumen is not possible. Surgery is warranted even if retrograde esophageal passage might fail, because open implantation of a jejunostomy catheter for enteral nutrition remains the only and ultimate palliative option in this situation.
Written consent was obtained from the patient for publication of this case report.
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