Tracheoesophageal fistula

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Esophagorespiratory fistulas most commonly occur between the trachea and the esophagus and are referred to as tracheo-esophageal fistulas. They may occur secondary to malignancy, radiation therapy, chemotherapy, or photodynamic therapy.

Malignant tracheo-esophageal fistula is a devastating and often terminal complication occurring in a variety of malignancies. In the largest series of tracheo-esophageal fistulas, 207 malignant cases were reported ( Bu.dLe.t...a.l 1991). The most common tumors resulting in fistulas were esophageal (78 per cent), lung

(16 per cent), and tracheal (2 per cent) carcinoma. The incidences of malignant tracheo-esophageal fistulas in patients with esophageal cancer and primary lung cancer are 4.5 per cent and 0.3 per cent respectively. The trachea is the most common site of fistulization, followed by the left and right mainstem bronchi.

In the series reported by Burt et al., 71 per cent, 11 per cent, and 9 per cent of patients had been treated with radiation therapy, resection, and chemotherapy respectively. Luketich,...e.t...a/ (..1.99.6.a..). reported a case of tracheo-esophageal fistula secondary to photodynamic therapy for malignant mesothelioma which was successfully treated by esophageal exclusion and gastric pull-up.

The majority of patients with malignant tracheo-esophageal fistulas are symptomatic. The most common symptoms are cough (56 per cent), aspiration (37 per cent), and fever (25 per cent). If tracheo-esophageal fistula is suspected, the diagnosis may be confirmed by chest radiography, CT scan of the chest ( Fig 2), barium swallow (Fig 3), esophagoscopy, or bronchoscopy.

Fig. 2 CT scan demonstrating a fistulous tract between the esophagus and right mainstem bronchus. This fistula developed secondary to lymph node invasion from intrathoracic Hodgkin's disease.

The survival of patients with malignant tracheo-esophageal fistulas primarily depends on the degree of pulmonary contamination and the performance status of the patient at the time of diagnosis. If significant pneumonia is present, most patients will die of respiratory failure within 30 days. Radiation therapy combined with esophageal bypass has resulted in the greatest survival advantage. Patients with minimal pulmonary involvement and good performance status should be considered for esophageal exclusion and gastric bypass.

Supportive care may be preferred in patients with pulmonary contamination or poor performance status. Immediate placement of a covered metallic stent may be effective palliation. As the time interval from diagnosis to treatment increases, the morbidity associated with tracheo-esophageal fistulas increases considerably.

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