Elsevier

Gastrointestinal Endoscopy

Volume 77, Issue 2, February 2013, Pages 181-189
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Stent-associated esophagorespiratory fistulas: incidence and risk factors

https://doi.org/10.1016/j.gie.2012.10.004Get rights and content

Background

Esophageal self-expandable stents (SESs) effectively treat strictures and leaks but may be complicated by a stent-associated esophagorespiratory fistula (SERF). Little is known about SERFs.

Objective

To determine the incidence, morbidity, mortality, and risk factors for SERF.

Design

Retrospective case-control study.

Setting

Single referral center.

Patients

All adults undergoing esophageal SES placement during a 10-year period.

Intervention

Stent placement.

Main Outcome Measurements

Occurrence of SERF, morbidity, and mortality.

Results

A total of 16 of 397 (4.0%) patients developed SERF at a median of 5 months after stent placement (range 0.4-53 months) including 6 of 94 (6%), 10 of 71 (14%), and 0 of 232 (0%) of those with lesions in the proximal, middle, and distal esophagus, respectively (overall P < .001). SERF occurred in 10% of those with proximal and mid-esophageal lesions, including 14% with benign strictures, 9% with malignant strictures, and none with other indications for SES placement (P = .27). The risk was highest (18%) in patients with benign anastomotic strictures. Risk factors for development of SERF included a higher Charlson comorbidity index score (odds ratio [OR] 1.47 for every 1-point increase; P = .04) and history of radiation therapy (OR 9.41; P = .03). Morbidity associated with SERF included need for lifelong feeding tubes in 11 of 22 (50%) and/or tracheostomy or mechanical ventilation in 5 of 22 (23%). Median survival after diagnosis was 4.5 months (range 0.35-67), and 7 patients survived less than 30 days.

Limitations

Retrospective design, limited statistical power.

Conclusion

SERF is a morbid complication of SES placement for strictures of the proximal and mid-esophagus. The dominant risk factors for development of SERF are prior radiation therapy and comorbidity score.

Section snippets

Methods

A retrospective cohort was established to identify the overall incidence and demographics of SERF. A case-control study was then performed to assess risk factors for development of SERF. The study was approved by the Mayo Clinic Institutional Review Board.

Results

A total of 443 patients who underwent esophageal stent placement were identified. A total of 46 were diagnosed as having ERF before stent placement and were excluded from this study. Of the remaining 397 patients, 16 were subsequently diagnosed with ERF. We also identified 5 patients who underwent esophageal stent placement at other institutions and who developed SERF and subsequently received care at our institution and 1 patient with SERF whose stent was placed before our predetermined time

Discussion

Symptom palliation is a major goal of treatment for many patients with esophageal cancer. Malignant dysphagia may be palliated with esophageal SESs,11 brachytherapy,12 chemoradiation therapy,13 photodynamic therapy,14 or surgery.15 Esophageal SESs are commonly used because of ease of insertion and demonstrated efficacy.1, 2, 3 SESs have become accepted in the treatment of benign esophageal conditions such as postoperative leaks, perforations, strictures, and fistulas.5, 6

Despite the benefits of

References (24)

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    We report an association between airway complications and previous surgery, radiotherapy, chemotherapy, and esophageal stenting. Previous studies have also reported a higher risk of TEF with esophageal stenting or radiotherapy.10-12 Development of TEF in these cases is multifactorial and is largely related to injury of the esophagus from radiation and expanding pressure of the stent.12

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

See CME section; p. 280.

If you would like to chat with an author of this article, you may contact Dr Topazian at [email protected].

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