Treatment Of Esophagorespiratory Fistula By Endoscopy

【PURPOSE】The purpose of this report is to explore the clinical features of esophagotracheal fistulas(ETF) and demonstrate our experience with therapeutic endoscopy in patients with ETF.【METHODS】81 patients of ETF treated in Shandong provincial hospital from January,2000 to October,2008 were analyzed on clinical materials.These patients with malignant ETF were randomly divided into two groups on the base of treatment pattern respectively,endoscopic treatment group(n=37)and non—endoscopic control group(n=32).Changes of clinical symptoms and laboratory indexes were recorded accordingly.The following variables were evaluated in assessing outcome: dysphagia score,disappearance time of tracheo-bronchial contamination,time of hospitalization,mean survival time.The results are expressed as means±SD. Follow—up study was for all the patients.The patients are evaluated every 4 weeks until death,and the maximum length of follow-up was 31 months.In some patients, evaluation was performed during outpatient visits,but usually follow-up phone calls were made.Further information about the ability to swallow including terminal dysphagia was obtained from the surviving patients,and(in some cases) the patients'relatives.【RESULTS】81 patients were retrospectively evaluated,in whom 69 patients were suffered of malignant esophagotracheal fistulas and 12 of benign fistulas.Thirty-two patients had grade 3 dysphagia and 23 had grade 3 dysphagia(79.7%,55/69) in 69 patients. The degree of dysphagia was not correlated with the diagnosis or the position of the fistulas.Clinical pathological stage of malignant esophagotracheal fistulas occurence were T₄N₀M₀ 4.3%(n=3),T₄N₀M_1a 8.7%(n=6),T₄N₁M₀ 13.0%(n=9),T₄N₁M_1a 36.2%(n=25),T₄N₁M_1b 37.7%(n=26),respectively.44 stents were successfully places in 35 of 37 endoscopic treatment group patients(94.6%,35/37)and 4 tracheal stents in 4 patients(10.8%,4/37).Fibrin glue was injected into the fistulas of 2 of 6 patients with esophagotracheal fistula alone,leading to complete occlusion of the fistulas. Before and after stent placement in endoscopic treatment group,a significant improvement in dysphagia score ranges from 3.1±0.91 to 1.21±0.71(P＜0.01). Statistically significant(P＜0.001)reduction of dysphagia was noted after endoscopic treatment.Compared with non—endoscopic control group,patients in Endoscopic treatment group had a significant improvement in dysphagia score and time of pneumonia disappearance and time of inpatient at follow—up study(p＜0.05 or p＜0.01).The survival time varied with the diagnosis.The mean survival time,146 days(range 7 to 281 days)in Endoscopic treatment group,96 days(range 17 to 266 days)in non—endoscopic control group,did not differ among two groups.No technical failures or procedural mortality or significant morbidity occured.All patients had got followed-up visits for average 20(range 5-37)months.Five patients were lost to follow up in the late follow up.【CONCLUSION】The therapeutic endoscopic technology can be used in the treatment of esophagotracheal fistula and it could be recommended as a first choice of modalities. Especially clinical useness of a self-expanding metal stent has become the new pattern of treatment choice for these unfortunate patients,which can occlude fistulas and hinder tumor overgrowth toward esophageal lumen and control tracheo-bronchial contamination.Self-expanding stents may be recommended as a valuable alternative to other methods for long-term palliation effect on dysphagia in patients with malignant esophagotracheal fistulas,which can improve the limited survival time and the living quality of these unfortunate patients which can improve the limited survival time and the living quality of these patients.