Perforations or fistulae involving the proximal third of the esophagus may be contained within the mediastinum or communicate with the airway via the membranous trachea. Fistulae that are contained within the mediastinum, depending on size, can be managed nonoperatively or by placing a closed drain in the mediastinum via a left neck incision. Caution should be exercised in placing SEMSs in the esophagus that extend proximally toward the hypopharynx as proximal migration can occur resulting in airway compromise and even asphyxiation. Proximal lesions involving the airway are better managed with a tracheal stent and a cervical drain.
Esophageal fistulae of the middle or distal third of the esophagus may involve the airway, one or both pleural spaces, the pericardium, the peritoneum, or the aorta (Fig. 25-1). These are best managed in the operating room with anesthesia and with supplies and equipment available, including flexible esophagogastroscope, flexible bronchoscope, thoracoscope, fluoroscopy, and a variety of sizes of completely covered SEMSs for the esophagus and airway. The presence of an esophageal– aortic fistula is usually a premorbid event; however, endoluminal aortic stenting may be considered to salvage these patients. In patients awaiting planned surgical resection following neoadjuvant chemoradiation, occasionally a heroic attempt at resection may allow urgent palliation if combined with an endograft or open aortic replacement. This should only be contemplated if the patient is in excellent condition; in the era of endografting, this would be the preferred primary approach.
Mid-esophageal perforation, contaminating the mediastinum and contained right pleural collection.
SEMSs are available in the United States from several different manufacturers and may be uncovered, partially covered, or fully covered. Fully covered stents are most appropriate in the management of malignant esophageal fistulae as they more effectively prevent ongoing leak from the esophagus and disrupt communication through the fistula tract. Fully covered SEMSs, as opposed to partially covered stents, are less prone to tissue ingrowth and thereby more easily removed or repositioned, but consequently also more prone to migration. Flexible esophagoscopy (Fig. 25-2A,B) should be performed in the operating room with fluoroscopy and a variety of lengths of large diameter SEMSs available. The fistula is visualized endoscopically and the proximal and distal extent marked with internal or external surface radiopaque marker under fluoroscopic guidance. The stent should be at least 4 cm longer than the desired area to be covered, which should include the entire length of the fistula and any tumor or stricture associated with, or distal to, the fistula (Fig. 25-3). If an obstructing tumor or stricture is present, it must be dilated to an internal diameter of 6 to 10 mm to permit passage of the predeployed stent delivery system. It is important to avoid overdilating the stricture as this may exacerbate the fistula as well as facilitate stent migration. It is important to attempt to limit the extent of the stent distally that resides across the lower esophageal sphincter and in the stomach, as this can promote reflux and aspiration and potentially lead to obstruction or ulceration through contact with the opposing gastric wall. If the CT scan suggests the presence of bulky tumor adjacent to the trachea posing a potential risk for external tracheal compression, then consideration should be given to placing a tracheal stent before placing an esophageal stent.
A. Endoscopy of esophageal perforation identified on CT scan. The communicating perforation can be visualized. B. True lumen is identified and guidewire is passed under direct vision and fluoroscopy guidance.
Placement of stent is seen as visualized by fluoroscopy as well as direct proximal visualization.
Decortication of the contaminated pleural space, including unroofing of any mediastinal abscess protruding into the pleural space (but contained by mediastinal pleura) and drainage of contaminated pleural or pericardial effusions, can usually be accomplished with video-assisted thoracoscopy. Routine drains should be placed as with any infected closed space. Rarely, consideration for an end esophagostomy should be entertained if the patient is becoming septic, although the long-term outcome from these situations is dismal.
If prolonged delay in resuming oral nutrition is anticipated because of complicating factors, such as pneumonia or respiratory compromise requiring mechanical ventilation, then a surgically placed feeding tube should be considered before leaving the operating room.