COMPARISON OF CONVENTIONAL AND WIRE MESH EXPANDABLE PROSTHESES AND SURGICAL BYPASS IN PATIENTS WITH MALIGNANT ESOPHAGORESPIRATORY FISTULAS

Background. Patients who present with malignant esophagorespiratory fi stula continue to provide a significant palliative challenge to gastro enterologists and surgeons. Methods. This retrospective series reviewe d 29 patients treated with conventional prostheses (13 patients), expa ndable wire mesh-coated prostheses (12 patients), and surgical bypass with esophageal exclusion (4 patients) between 1982 and 1995. Results. Improvement in dysphagia scores were comparable in all three groups. Fistula occlusion was more successful with expandable prostheses (92%) compared conventional prostheses (77%); however, reinterventions were required more commonly with expandable prostheses, which were also si gnificantly more expensive on a unit cost basis. In selected patients in whom prosthesis placement either was inappropriate or failed, surgi cal bypass and esophageal exclusion was undertaken. These patients dem onstrated good palliation with minimal morbidity and no mortality. Con clusions. Both conventional and expandable prostheses are safe and rea sonably straightforward treatment modalities for patients with esophag orespiratory fistulas. because of ease of insertion and large luminal diameter, expandable metal prostheses will see increasing use in treat ment of these difficult patients; however, conventional prostheses wil l remain a good alternative, especially in patients with extrinsic eso phageal compression. When stent placement is either unsuccessful or in advisable, physiologically fit patients can undergo surgical bypass an d esophageal exclusion with good palliation and minimal morbidity and mortality. (C) 1998 by The Society of Thoracic Surgeons.