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Laparotomy enables retrograde dilatation and stent placement for malignant esophago-respiratory fistula.

Rehders A, Cupisti K, Schmitt M, Renter MA, Kröpil P, Iskender O, Knoefel WT - World J Surg Oncol (2008)

Bottom Line: Using a guidewire the esophageal obstruction was traversed and dilated.Then it was possible to place an esophageal stent via an antegrade approach.Open surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.

View Article: PubMed Central - HTML - PubMed

Affiliation: Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Heinrich Heine Universität, Düsseldorf, Germany. rehders@med.uni-duesseldorf.de

ABSTRACT

Background: Malignant esophageal stenosis with complete obstruction and esophagorespiratory fistula (ERF) is difficult to treat with standard endoscopic techniques.

Case presentation: We report a patient in whom with local recurrence of esophageal carcinoma an esophagotracheal fistula occurred. Initially the patient had undergone esophageal resection with interposition of a gastric tube. Due to complete obstruction of the lumen by recurrent tumor conventional transoral stent placement failed. For retrograde dilatation a laparotomy was performed. Via a duodenal incision endoscopic access to the gastric tube was achieved. Using a guidewire the esophageal obstruction was traversed and dilated. Then it was possible to place an esophageal stent via an antegrade approach.

Conclusion: Open surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.

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Retrograde endoscopic access to the esophageal lumen was obtained by open surgery and a duodenotomy.
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Figure 3: Retrograde endoscopic access to the esophageal lumen was obtained by open surgery and a duodenotomy.

Mentions: All endoscopic attempts to pass the obstruction failed, because the guide wire only entered the associated esophago-tracheal fistula. Therefore a retrograde endoscopic approach was undertaken. According to the previous esophageal resection with interposition of a gastric tube, radiologically guided percutaneous gastrostomy techniques [5] had to be rejected. Retrograde access to the esophageal lumen was obtained by open surgery and a duodenotomy (Figure 3). Through an endoscope a guide wire (Terumo, RF-GA35403M Standard, 0.035 inch) was pushed up and the esophageal obstruction was traversed, which simultaneously was monitored by a transnasal endoscope. Using a guiding catheter the esophageal stenosis was dilated and a naso-jejunal triluminal feeding tube was placed into the first jejunal loop. Subsequently the longitudinal duodenal incision was closed in a transverse fashion. Before closure of the abdominal wall a jejunostomy catheter was implanted to ensure sufficient enteral nutrition. 72 hours later, in a second step further endoscopic guided dilatation of the esophageal stenosis was repeated twice. Using a stiff wire (0.035 inch) placed under fluoroscopic control subsequent guide wired dilatation, up to 12.8 mm according to the method of Savary, was performed. In a third step a nitinol self-expanding fully covered stent, the so called Choo stent (M.I. Tech/MTW), was placed across the fistula under radiological and endoscopic control (Figure 4). After successful placement of the stent the upper end was located directly proximal from the stenosis at about 20 cm from frontal incisors and completely traversed the whole stenosis. As a result the patient felt neither foreign body sensation nor pain. A follow up contrast study, performed on the 4th day after stent placement, showed the stent to be almost completely expanded without any signs of persisting leakage. Thereafter the patient was allowed to swallow liquid food, although only a small volume could be swallowed at a time. A few days later swallowing of semi solids and hypercaloric liquid food was possible and the patient was discharged.


Laparotomy enables retrograde dilatation and stent placement for malignant esophago-respiratory fistula.

Rehders A, Cupisti K, Schmitt M, Renter MA, Kröpil P, Iskender O, Knoefel WT - World J Surg Oncol (2008)

Retrograde endoscopic access to the esophageal lumen was obtained by open surgery and a duodenotomy.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2267468&req=5

Figure 3: Retrograde endoscopic access to the esophageal lumen was obtained by open surgery and a duodenotomy.
Mentions: All endoscopic attempts to pass the obstruction failed, because the guide wire only entered the associated esophago-tracheal fistula. Therefore a retrograde endoscopic approach was undertaken. According to the previous esophageal resection with interposition of a gastric tube, radiologically guided percutaneous gastrostomy techniques [5] had to be rejected. Retrograde access to the esophageal lumen was obtained by open surgery and a duodenotomy (Figure 3). Through an endoscope a guide wire (Terumo, RF-GA35403M Standard, 0.035 inch) was pushed up and the esophageal obstruction was traversed, which simultaneously was monitored by a transnasal endoscope. Using a guiding catheter the esophageal stenosis was dilated and a naso-jejunal triluminal feeding tube was placed into the first jejunal loop. Subsequently the longitudinal duodenal incision was closed in a transverse fashion. Before closure of the abdominal wall a jejunostomy catheter was implanted to ensure sufficient enteral nutrition. 72 hours later, in a second step further endoscopic guided dilatation of the esophageal stenosis was repeated twice. Using a stiff wire (0.035 inch) placed under fluoroscopic control subsequent guide wired dilatation, up to 12.8 mm according to the method of Savary, was performed. In a third step a nitinol self-expanding fully covered stent, the so called Choo stent (M.I. Tech/MTW), was placed across the fistula under radiological and endoscopic control (Figure 4). After successful placement of the stent the upper end was located directly proximal from the stenosis at about 20 cm from frontal incisors and completely traversed the whole stenosis. As a result the patient felt neither foreign body sensation nor pain. A follow up contrast study, performed on the 4th day after stent placement, showed the stent to be almost completely expanded without any signs of persisting leakage. Thereafter the patient was allowed to swallow liquid food, although only a small volume could be swallowed at a time. A few days later swallowing of semi solids and hypercaloric liquid food was possible and the patient was discharged.

Bottom Line: Using a guidewire the esophageal obstruction was traversed and dilated.Then it was possible to place an esophageal stent via an antegrade approach.Open surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.

View Article: PubMed Central - HTML - PubMed

Affiliation: Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Heinrich Heine Universität, Düsseldorf, Germany. rehders@med.uni-duesseldorf.de

ABSTRACT

Background: Malignant esophageal stenosis with complete obstruction and esophagorespiratory fistula (ERF) is difficult to treat with standard endoscopic techniques.

Case presentation: We report a patient in whom with local recurrence of esophageal carcinoma an esophagotracheal fistula occurred. Initially the patient had undergone esophageal resection with interposition of a gastric tube. Due to complete obstruction of the lumen by recurrent tumor conventional transoral stent placement failed. For retrograde dilatation a laparotomy was performed. Via a duodenal incision endoscopic access to the gastric tube was achieved. Using a guidewire the esophageal obstruction was traversed and dilated. Then it was possible to place an esophageal stent via an antegrade approach.

Conclusion: Open surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.

Show MeSH
Related in: MedlinePlus