Chapter 23

Malignant esophageal fistula is a difficult complication of a devastating illness. Its management can be trying for even the most experienced of surgeons. A team approach is necessitated by the demanding and complex nature of the underlying biologic process. The surgeon must have specialized skills for operating on the esophagus, expertise in endoscopy, and cooperation from oncology, pulmonology, gastroenterology, otolaryngology, nutrition, and radiation oncology, among other hospital departments. Locally advanced malignant esophageal fistulas have been described in the upper, middle, and lower esophagus. Fistulas can involve the trachea, bronchi, pleural space, lung, mediastinum, peritoneum, pericardium, and even the great vessels. The organ or space affected by the spread of cancer is integral to devising an effective treatment plan whether the goal is curative resection, rarely an option for these patients, or palliation. While malignant esophageal fistulas can occur anywhere along the course of the esophagus, the form most commonly encountered in thoracic surgical practice is the esophagorespiratory fistula and hence the principal focus of this chapter.

Fistulas complicate locally advanced esophageal carcinoma at a rate of approximately 13%.1 In staging patients with esophageal or proximal stomach malignancies, the presence of a malignant fistula is considered T4 disease according to the American Joint Cancer Committee (AJCC) Cancer Staging Manual2 because the process invades contiguous structures. Preoperative T4 disease is minimally categorized as stage III disease and usually is deemed unresectable. Without nodal or metastatic involvement (T4N0M0), maximum 5-year survival is 15%,3 but lower survival rates are usually reported. Survival diminishes for the subgroup of patients with esophagorespiratory fistula, and nodal spread compounds the condition, further reducing survival.

Controlling the primary disease process is an important principle of surgical treatment. Long-term survival is a rare possibility for patients with esophageal cancer and is confined to primary tumors that have not transgressed the esophagus. In patients who remain free of nodal or metastatic involvement (N0M0), aggressive chemoradiation may be undertaken, and if the patient has a complete pathologic response, long-term survival is possible. Surgical resection for cure thus is recommended for esophagorespiratory fistulas in patients with N0M0 disease who have a complete pathologic response to neoadjuvant therapy. When the esophagorespiratory fistula is located distally in the respiratory tree, en-bloc pulmonary resection may be considered, and the patient is fully staged at T4N0M0.4 Even this approach is considered controversial because in the setting of microscopic nodal disease, which is probable if the primary disease has led to development of an esophagorespiratory fistula, extensive resection would not be recommended. This is underscored by the fact that in patients in whom preoperative T4N0M0 disease has been fully resected, the cause of mortality is usually distant disease, not local recurrence.

The basic tenet of surgical treatment of esophagorespiratory fistula is soilage control. Even a locally ...

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