Surgical treatment of malignant esophagotracheal fistulas

Malignant esophagotracheal fistulas represent the fatal evolution of esophageal cancer. Since October 1974, 18 patients were seen who had confirmed esophagotracheal fistula, and in half of these patients, the fistula was the revealing symptom. Upper gastrointestinal studies (using hydrosoluble dye) and bronchoscopic examination confirmed the diagnosis, which was already strongly suspected in 16 of the patients due to the specific nature of the cough triggered by swallowing. The average age of the patients was 57 years, (range, 32 to 78 years). In 12 patients, the nutritional repercussions were moderate, and in only 6 patients, were the bronchopulmonary consequences serious. Therapeutically, we adopted a palliative surgical attitude since the physical and psychological condition of these patients was considered fatal the month after discovery of the fistula. In addition, the results of intubation were uncertain and transitory. Our surgical methods evolved in three stages: first, we performed bipolar exclusion of the esophagus coupled with gastrostomy (four patients), second, we performed retrosternal coloplasty (five patients), and third retrosternal gastroplasty with drainage of the inferior portion of the esophagus by Roux-Y jejunal anastomosis (six patients). The latter technique was inspired from that described by Kirschner in 1920. It is moderately aggressive and has the advantage of dealing with several objectives: exclusion of the fistula, reestablishment of normal alimentation, drainage of the inferior portion of the esophagus, and permitting postoperative radiotherapy. In our series, when only the patients who underwent coloplasty or gastroplasty were considered, 3 of 11 died, and the longest postoperative survival times were 16 and 23 months. Regarding gastroplasty alone, our results were in agreement with those in the literature. In the 19 patients who underwent gastroplasty, the operative mortality was 31.5 percent and the average length of survival was 9 months. Six patients survived from 8 to 26 months. Therefore, this "last resort" surgery seems legitimate in light of the fact that the results are sometimes superior to those of radical curative surgery for extirpative esophageal cancer.