Surgical treatment of esophageal carcinoma complicated by fistulas

Objectives: The locally advanced esophageal carcinoma can be complicated by fistulas. According to published data, the incidence rate of malignant eso phageal fistulas is about 13%. The range of treatment modalities proposed b y different authors varies from palliation to active and, if possible, radi cal surgical interventions. In the present study, we investigated combined esophagectomies as a radical treatment of the malignant esophageal fistulas . Methods: Thirty-five patients (aged 28-67) with malignant esophageal fist ulas of different localizations were operated over a period from 1990 to 20 00. The tumor was located in the upper, middle and lower thoracic esophagus in four, 20 and I I cases, respectively. The malignant fistula with the me diastinum, pleural cavity, lungs, bronchi and trachea was observed in 21, t wo, five, four and three cases, respectively. Subtotal esophagectomy and es ophagogastroplasty were performed in 18 patients; subtotal esophagectomy wi th intrapleural coloesophagoplasty was performed in one case; proximal gast ric and lower thoracic esophageal resection from the left-side abdominothor acic approach was performed in three cases. Esophagogastric bypass anastomo ses were formed in ten patients. Gastrostomy was performed in three patient s. Results: The complication rate was 40% (14 out of 35); the postoperative mortality was 14.3% (five out of 35). In patients after esophageal resecti on, the mortality rate was 13.6% (three out of 22). With a median survival of 13 months (range, 3-31), the 2-year survival rate was 21% after combined esophagectomies. Conclusions: The goal of surgery for esophageal cancer wi th various fistulas is to completely resect the primary tumor and involved adjacent structures with clear surgical margins and extended two-field lymp hadenectomy. The importance of performing a complete resection is stressed by the absence of 1-year survivors among patients who underwent bypass surg ery or gastrostomy. We consider that en-bloc combined resection of esophage al cancer complicated by fistula can be done with a low mortality. (C) 2001 Elsevier Science BN. All rights reserved.