European Journal of Cardio-Thoracic Surgery, Vol 11, 38-45, Copyright © 1997 by European Association for Cardio-thoracic Surgery
Management of non resectable malignant esophageal stricture and fistula
D Dougenis, T Petsas, N Bouboulis, C Leukaditou, C Vagenas, D Kardamakis and F Kalfarentzos
Department of Surgery, Regional University Hospital, Patras, Greece.
OBJECTIVE: The palliation of dysphagia caused by esophageal carcinoma and
other inoperable tumours obstructing the esophagus presents a challenge for
the thoracic surgeon, in particularly when associated with fistula (F). In
a prospective study over the last 5 years, we have evaluated the
effectiveness of different approaches and types of prostheses to solve the
above problem. METHOD: Thirty three patients (mean age: 63.5 years, range
42-76, M/F:24/9) with inoperable tumours obstructing the esophagus
underwent intubation and/or palliative surgery according to the following
protocol: (1) Preoperative esophagography; (2) endoscopy and biopsy; (3)
dilatation and insertion of prosthesis usually under general anaesthesia;
and (4) re-evaluation the following day, in 30 days and as required
thereafter. Prosthesis used were: Atkinson 3, Wilson-Cook (plain) 12,
Wilson-Cook (cuffed) 4, Strecker (metallic self-expandable) 13. The
patients were divided in three groups according to the extension of the
disease: group A (n = 19) plain malignant strictures, group B (n = 5)
strictures with respiratory Fs, group C (n = 9) strictures with mediastinal
or pleural Fs. RESULTS: All patients of group A had successful palliation
irrespectively of prosthesis used and site of obstruction. One patient
required two stents. There was no death and 50% survival at 6 months was
70%. In group B, a cuffed prosthesis successfully closed two
bronchoesophageal Fs, while three patients underwent retrosternal bypass
surgery. There was one death on the 26th postoperative day. In group C, one
Strecker, two plain Wilson-Cook and two cuffed Wilson-Cook stents, although
initially succeeded, in due course, failed to block the Fs in five patients
who subsequently underwent bypass surgery with one death. With four
patients both leak and dysphagia were significantly improved with the use
of self-expandable stents therefore, not requiring surgery. Overall, there
were two deaths but no failure in palliating dysphagia. Longer survival was
20 months. Patients with fistulae had poorer prognosis as compared to those
suffering from plain malignant stricture (P = 0.01). CONCLUSIONS: Plain
malignant inoperable oesophageal strictures can be successfully palliated
with intubation. Complicated with fistula strictures, however, are
difficult to manage and have a poor prognosis. Due to the fact that bypass
surgery is associated with an increased mortality, it should be kept for
those with late stent failures and fistula recurrences.
