Combined endoscopical treatments for tracheo-esophageal fistula developed during V-V ECMO for severe COVID-19: A case series.
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ABSTRACT:
SUBMITTER: Granata A
PROVIDER: S-EPMC8653176 | biostudies-literature | 2021 Nov
REPOSITORIES: biostudies-literature
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Combined endoscopical treatments for tracheo-esophageal fistula developed during V-V ECMO for severe COVID-19: A case series.
Granata Antonino A Martucci Gennaro G Rizzo Giacomo Emanuele Maria GEM Arcadipane Antonio A Traina Mario M
Artificial organs 20211109 3
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Project description:Introduction and importanceThe management of large malignant tracheo-esophageal fistulas (TEF) is not standardized. Herein, we report a case with a malignant TEF associated with esophageal post-transplant lymphoproliferative disorder (PTLD) for whom we successfully performed a surgical repair. This contributes to the knowledge on how to treat large acquired malignant TEFs.Case presentationA 69-year old male presented with a one-week history of fever, productive cough and bilateral coarse crackles. In addition, he described a weight loss of 10 kg during the past three months. The patient's history included a kidney transplantation twenty years ago. Esophagogastroduodenoscopy with a biopsy of the esophagus was performed nine days before. Histopathology showed a PTLD of diffuse large B-cell lymphoma subtype. Subsequent diagnostics revealed a progressive TEF (approx. 2.0 × 1.5 cm) 3.0 cm above the carina. PET-CT scan showed an esophagus with slight tracer uptake in the middle third (approx. 11.5 cm length, SUV max 7.4). After decision against stenting, transthoracic subtotal esophagectomy with closure of the tracheal mouth of the fistula by a pedicled flap was performed. PTLD was treated with prednisone and rituximab. Tumor progression (brain metastasis) led to death 95 days after surgery.Clinical discussionThe treatment of a malignant TEF is complex and personalized while both the consequences of the esophago-tracheal connection and those of the underlying responsible diagnosis have to be considered concurrently. In this case, we considered surgery as the best treatment option due to a relatively good prognosis of the underlying diagnosis (PTLD) and a large fistula. Esophageal or dual stenting, the treatment of choice for small malignant TEF, would have been associated with a high risk of failure due to the wide trachea, extensively dilated esophagus, proximal location and large diameter of the fistula.ConclusionSurgery can be considered for patients with a large acquired malignant TEF and positive long-term prognosis of the underlying diagnosis. Due to the complexity of TEF management, immediate pre-operative multidisciplinary discussion is advised.
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Project description:Clinical presentation and management modalities for 585 patients of esophageal atresia and/or tracheo-esophageal fistula reporting to Department of Paediatric Surgery, SMS Medical College, Jaipur over twenty five years (1972-1996) were analyzed in five phases of five years each retrospectively. Over the period of observation, the incidence of new cases as well the number of associated anomalies have shown a steady increase due to availability of modern diagnostic facilities. The operative mortality has shown a progressive decline from 95% early in the series to 40% in last few years. Post-operative anastomotic leaks occurred in 21% of cases, strictures in 8% and recurrent fistula in 1% of cases. The presence of severe associated anomalies, prematurity, pulmonary complications and sepsis still remain the major killers in our setup. Early detection and referral has lead to more infants reaching the specialized centres with less pulmonary complications. In the last decade, the survival rate for infants in Waterston's risk group A has improved to 86% but there is still a substantial difference in the survival rate reported from developed countries. The various factors resulting in poorer results in our set up have been highlighted.
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