Fistula malignant

This chapter will describe the various treatments for esophageal cancer and their place in the management of patients with this disease. The main body of the chapter will be devoted to a description of metallic stents, the techniques of insertion, results of stenting, the management of complications, and a description of the role of stents in the management of malignant fistulas and perforations. 

Malignant fistulas between the esophagus and the respiratory system are a serious complication of esophageal cancer and occur in 5%-15% of patients (Martini et al. 1970 Little et al. 1984 Duranceau and Jamieson 1984). They may arise spontaneously as a result of tumor invasion or they may be caused by radiation therapy, surgery, pressure necrosis caused by a previously placed plastic or metallic stent, or laser therapy (Burt et al. 1991 Duranceau and Jamieson 1984 Saxon et al. 1994 Cwikiel et al. 1998). The onset of symptoms of aspiration is a devastating development for patients aheady debilitated by malnutrition caused by the dysphagia. Patients are often unable to swallow their own saliva without aspirating. 

With the introduction of plastic-covered metallic stents for the palliation of malignant dysphagia, interventionists found that these devices were also very effective at closing fistulas and perforations. Metallic stents are better that plastic stents in this regard because they expand to the diameter of the esophagus and the covering material provides an effective seal over the defect (Watkinson et al. 1995b Do et al. 1993). 

The technique is very similar to the procedure for palliation of malignant dysphagia. Preprocedural esophagography should be performed with nonionic contrast medium to confirm the presence of the fistula or perforation and to identify its approximate location in the esophagus. With the patient in the left-lateral position, a catheter is passed into the esophagus to the site of the lesion. The exact location of the fistula or perforation is defined by the direct injection of contrast medium into the esophagus. The site is marked with the use of residual contrast medium at the site of the defect, bony landmarks, or a surface marker. 

The results of the largest series of stenting for malignant fistulas and perforations are presented in Table 2.3 (Morgan et al. 1997 Saxon et al. 1995 Han et al. 1996 Mohammed and Moss 1996 Nicholson et al. 1995 Raijman et al. 1998). All types of covered stents have been found to be effective in the treatment of leaks and fistulas. Clinical success, defined as successful closure of the fistula or leak, occurs in 67%-100% of patients. The largest series involved 39 patients with 19 perforations and 20 fistulas, treated with covered Wallstent endoprostheses (36 patients) and covered Gianturco stents (three patients) at Guy s Hospital. The technical... 

Table 2.3. Results of metallic stenting for the palliation of malignant esophagorespi-ratory fistulae and perforations...

The complications of stenting for malignant fistulas and perforations are similar to those reported for the use of stents in malignant dysphagia. 

Covered metallic stents provide effective treatment for malignant flstulas and perforations. The clinical success rates are very high and most patients derive relief from symptoms of aspiration or debilitating thoracic sepsis. Patients with recurrent flstulas or leaks may be treated by additional overlapping stents in most cases. Metallic stents placed in the airways may be useful for some patients with a dilated esophagus, very high fistulas, or airway obstruction due to local invasion by esophageal tumors. 

Burt M, Delhi W, Martini N, et al. (1991) Malignant oesophageal fistula management options and survival. Ann Thorac Surg 52 1222-1229... 

Morgan RA, Ellul JPM, Denton ERE, et al. (1997) Malignant esophageal fistulas and perforations management with plastic-covered metallic endoprostheses. Radiology 204 527-532... 

Mohammed S, Moss J (1996) Palliation of malignant tracheo-oesophageal fistula using covered metal stents. Clin Radiol... 

Fig. 7.8a,b. Patient with malignant vesico-vaginal fistula. The patient had a solitary kidney, a Nephrostomy, b Detachable balloon (filled with contrast medium) occluding the lower ureter... 

Placement of tracheobronchial stents for malignant obstructions or fistulas is not without complications. Plastic and metallic stents have different complication profiles. Some stents have their specific complications owing to the dedicated design. 

In patients with high-flow priapism and complex traumas undergoing contrast-enhanced CT with state-of-the-art multiple detector-row systems, the arterial-sinusoidal fistula can he identified (Fig. 10.8). This examination, however, cannot replace angiography, because interventional maneuvers cannot be performed. In malignant priapism contrast-enhanced CT is indicated to evaluate the perineal and pelvic extent of the disease. In patients with priapism secondary to aortocaval fistula contrast-enhanced CT reveals the communication between the aorta and the inferior vena cava and congestion of the pelvic vessels (Abela et al. 2003 Gordon et al. 2004). Poor enhancement of the kidneys reveals renal hypoperfusion. 

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