Esophagorespiratory Fistulas

• A debilitating complication of esophageal malignancy is esophagorespiratory fistula (ERF)  This complication develops in 5% to 15% of esophageal cancer patients.  Untreated ERF invariably leads to paroxysmal coughing, profound malnutrition, recurrent pneumonias, and, ultimately, early death.  Palliation in such patients involves restoration of their ability to swallow and prevention of aspiration.  Until recently, the treatment of choice has been placement of a rigid plastic tube in the esophagus.  However, these devices have been associated with a significant incidence of complications, such as esophageal perforation, hemorrhage, obstruction, and stent migration.  Preliminary results with covered, self-expanding metal stents suggest that these endoprostheses produce a safer and more effective method for palliation of ERF.
  
  

• In patients with an ERF due to malignancy, there is almost always an associated esophageal stricture present.  The procedure for placement of a covered self-expanding metal stent to occlude the fistula is identical to that for treatment of a malignant stricture alone.  However, after stent placement, patients with ERF should be instructed to begin eating a soft food diet, initially avoiding liquids.  If no symptoms of aspiration occur on this diet, then liquid intake can be introduced.  Other than this diet modification, postprocedure monitoring is be identical to that described previously.
  
  

• Covered stent placement in patients with ERF has been reported to achieve sustained relief of aspiration symptoms in 70-75% of patients with lesser degrees of improvement in the remainder.  Fluoroscopic guidance enables precise localization of the fistula and strictured segment and allows more accurate stent placement than endoscopic guidance.