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Letters to the Editor |
Semmelweis University Budapest, Department of Surgery, 
ll
i u. 78, 1082, Budapest, Hungary
Received 18 March 2009; accepted 20 March 2009.
* Corresponding author. Tel.: +36 1 313 52 16; fax: +36 1 314 34 31. (Email: balazsdr{at}gmail.com).
Key Words: Malignant respiratory fistulas • Palliation • Effectiveness
The most effective way of palliation of esophagorespiratory fistulas is finding the most appropriate procedure that adapts to the given morphological situation.
We would like to thank Dr Kotsis for his interest and the reflection [1] on our study [2]. The pallation of esophagorespiratory fistulas is a huge challenge since a double problem needs to solved. It is not only necessary to seal the fistula but also to restore the ability to swallow. In our opinion the main question is not to determine the best way of stenting but to find the one that adapts best to the given morphological situation. This is the key to success. In our practice both the push-through and the pull-through techniques have been used. The endoscopic method has overtaken the operative way because of its benefits, but there is still a number of situations when the latter is the method of choice. In our experience the self-expanding metal stents have met the necessary requirements more frequently than the rigid tubes. The selection of the appropriate type and size of the prosthesis needs to be individual. The stents must be covered. In our study the pathological communication was sealed by esophageal intubation in 76.6% of the cases. Endobronchial or tracheobronchial stent implantation could also give an additional opportunity, but this method was not used in our patients mainly because of the lack of proper conditions. In 72 cases stent implantation was impossible to be carried out. The reasons were: 24 total obstructions, 18 too high strictures, 4 outer compressions, 5 mild strictures (not able to keep the prosthesis in place), 9 necrotizing tumorous cavities, 3 angulations and axis deviations, 7 very poor general states, and 1 refusal. In these cases there was no chance a successful palliation of esophagorespiratory fistulas which determined their survival and quality of life. There has also been a number of further palliative treatment possibilities (restenting, laser, etc.) for these patients, but the deterioration of their clinical status has prevented their use. Cuffed funnel tubes or double cuffed tubes give additional opportunities, especially in the management of the wide hollow necrotizing tumorous cavities. In our opinion the use of covered self-expanding stents in esophagorespiratory fistulas is treatment of choice and the new types of prostheses seem to promising.
References
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