Janusz Włodarczyk

Esophago-Pericardial Fistula During the Course of Primary Esophageal Carcinoma

The study presented a case of an esophago-pericardial fistula during the course of primary esophageal carcinoma. The occurrence of this was insidious, with the first symptom being pericardial sac tamponade. After full diagnostics the patient was qualified for surgery. The patient was subjected to videothoracoscopy, left-sided thoracotomy, fenestration, and pericardial sac drainage, with placement of a self-expandable esophageal prosthesis. During the course of the disease the patient required bronchial tree patency restoration and prosthesis application. The patient survived 329 days.

Iatrogenic injuries to the trachea and main bronchi

Introduction Iatrogenic tracheobronchial injuries are rare. Aim To analyse the mechanism of injury, symptoms and treatment of these patients. Material and methods Retrospective analysis of hospital records of all patients treated for main airway injuries between 1990 and 2012 was performed. Results There were 24 patients, including 21 women and 3 men. Mean time between injury and initiation of treatment was 12 hours (range: 2-48). In 16 patients the injury occurred during tracheal intubation, in 1 during rigid bronchoscopy, in 1 during rigid oesophagoscopy, in 1 during mediastinoscopy and in 5 during open surgery. Mean length of airway tear was 3.8 cm (range: 1.5-8). In 1 patient there was an injury to the cervical trachea and in the remaining 23 in the thoracic part of the airway. The treatment included repair of the membranous part of the trachea performed via right thoracotomy in 10 patients (in 1 patient additionally coverage with a pedicled intercostal muscle flap was used), a self-expanding metallic stent in 1 patient, suture of the right main bronchus and the oesophagus in 1, left upper sleeve lobectomy in 1, right upper lobectomy in 1, implantation of a silicone Y stent in 3, mini-tracheostomy in 1, and conservative treatment in 5 patients. Conclusions Intubation is the most frequent cause of iatrogenic main airway injuries. Patients with these life-threatening complications require an individualised approach and treatment in a reference centre.

Double stenting for malignant oesophago-respiratory fistula

Introduction The close anatomical relationship between the oesophagus and bronchial tree results in formation of an oesophago-respiratory fistula in a subset of patients with advanced oesophageal or lung cancer. In those patients stenting of both the oesophagus and tracheobronchial tree is a valid option of palliative treatment. Aim To determine the effectiveness, tolerance, quality of life, safety and survival after double stenting procedures. Material and methods Retrospective analysis of a prospectively collected database was performed, concerning consecutive patients with oesophago-respiratory fistulas treated with double stenting. In all patients the degree of dysphagia, respiratory function before and after the procedure, and quality of life were evaluated. Partially covered oesophageal self-expanding metallic stents (PCESEMS) were used for oesophageal stenting, and silicone Y-type or partially covered self-expanding bronchial and tracheal stents (PCASEMS) were used to restore airway patency. Results Between 2003 and 2015, 31 patients underwent double stenting due to oesophago-respiratory fistulas. Twenty-nine patients were diagnosed with oesophageal squamous cell carcinoma and 2 with bronchial carcinoma. In all patients, improvement in the general condition and quality of life was observed after airway patency restoration. Two patients required mechanical ventilation due to respiratory failure immediately after the procedure. Seven patients with oesophageal fistulas died because of bleeding in the long-term follow-up. Four patients required endoscopic re-intervention. Mean survival time was 67.1 days. Conclusions Double stenting is an effective procedure improving patients’ quality of life. However, life-threatening complications can occur.

Stenting as a palliative method in the management of advanced squamous cell carcinoma of the oesophagus and gastro-oesophageal junction

Advanced squamous cell carcinoma of the oesophagus and gastroesophageal junction usually requires palliative treatment, and the method of choice is stenting. There are several types of stents currently available, including: self-expandable metallic stents (fully or partially covered); self-expandable plastic stents; biodegradable stents. Each of the mentioned stents has its advantages and limitations, and requires a proper, patient-tailored selection. Due to the close anatomical relationship between the oesophagus and bronchial tree, some patients may require bilateral stenting. Oesophageal stenting may not only be considered as a palliative procedure, but can also be implemented to alleviate dysphagia during preoperative chemotherapy and/or radiotherapy.

Safety and efficacy of oesophageal stenting with simultaneous percutaneous endoscopic gastrostomy as a supplementary feeding route in unresectable proximal oesophageal cancer

Introduction Proximally located oesophageal cancer poses an especially difficult problem in terms of restoration of patency and the stenting procedure. Supplementary percutaneous endoscopic gastrostomy (PEG) may be useful in these patients. Aim To assess the safety of the stenting procedure in the proximal oesophagus in patients with unresectable upper oesophageal cancer, performed simultaneously with PEG insertion. Material and methods Patients with obstructing upper oesophageal tumours were scheduled for an oesophageal stenting procedure and simultaneous PEG insertion. Degree of dysphagia, body weight loss, daily energy requirement, body mass index and performance status before and after the stenting procedure as well as complications were assessed. Results Forty-five patients aged 19–88 years were included in the study. Six of them had a fistula to the trachea and underwent stenting of the oesophagus or both the oesophagus and the airway. The technical success rate was 100%. Following the procedure all patients were able to swallow fluids and semi-liquids, and PEG was used as the primary feeding route. Body mass index increased from 20.4 to 21.1 (p = 0.0001), body weight gain improved from –10.1 to +2.0 kg and metabolic requirements improved (p = 0.0001). Also, the Karnofsky score improved significantly (56.7 vs. 65.1, p = 0.0001). Mean survival time was 133 days (range: 36–378). Conclusions Stenting of the proximal oesophagus with simultaneous PEG is a safe procedure, allowing the patients to resume oral intake of liquids whilst improving nutritional status and general performance, with an acceptable rate of complications.

Safety and efficacy of airway stenting in patients with malignant oesophago-airway fistula

Background Close anatomical relationships between the oesophagus and the bronchial tree can lead to the formation of oesophageal fistula particularly in patients with advanced lung or oesophageal carcinoma. Stenting is a most often used treatment in such patients, but data regarding the relative value of unilateral (US) vs. double stenting (DS) are scarce. Methods Retrospective analysis of hospital records of patients with oesophageal fistula who underwent stenting between 2008 and 2016. In those in whom airway stenosis was >30%, double stenting (oesophagus and bronchial tree) was performed, whereas in those with lesser airway stenosis unilateral stenting (i.e., oesophagus only) was performed. In all patients, the degree of dysphagia, the degree of dyspnoea and the quality of life were assessed before and after the stenting. Results There were 46 patients, analysed, including 26 who underwent DS and 20 patients who underwent US. Both, DS and US resulted in significant improvement of dysphagia (2.72 vs. 1.2, P=0.0001 and 2.65 vs. 1.0, P=0.0001), dyspnoea (2.89 vs. 0.34, P=0.0001 and 1.71 vs. 0.09, P=0.0001) and performance score (53.2 vs. 66.3, P=0.0001 and 54.3 vs. 62.38, P=0.0001). Neither fistula type, nor stenting method, weight loss and gain, and BMI, had an effect on survival (P=0.34). Disease progression and recurrence of fistula requiring re-intervention occurred in 9 patients (19.5%). Conclusions Double and unilateral stenting is an effective measure to alleviate dysphagia and dyspnoea in patients treated with malignant oesophageal fistula. In those with airway stenosis of ≤30%, stenting of the oesophagus only, instead of DS, is a safe method of treatment.

Lymph node metastasis in oesophageal cancer—what we (do not) know?

Although many aspects of the treatment of oesophageal cancer remain controversial, one of them is beyond doubt: prognosis in this disease is still poor, with overall 5-year survival slightly over 10% (1). One of the most important issues determining prognosis is metastatic spread in the lymphatic system. The mechanism of this spread is poorly understood, as is the role of lymphadenectomy. Whilst there are ongoing discussions on the impact of lymph node dissection on survival, it is generally agreed that lymphadenectomy enables accurate staging and, therefore, is important for prognostic purposes. However, high quality scientific data regarding many factors related to this issue are scarce.

Composite metrics in response assessment—new hope in oesophageal cancer?

Oesophageal cancer is still associated with poor prognosis. The progress in systemic treatment, radiation therapy and surgery over the last decades has resulted in only moderate improvement of survival. Neoadjuvant chemoradiotherapy (CRT) has been shown to be associated with tumour response in 60–70% of patients (1), and with complete pathological response (CPR) in 25–30% of patients (2,3). Although it reportedly improves survival, there are several concerns about its routine use. Besides the treatment-related toxicity, the most important issue is lack of reliable predictive factors for pathological tumour and nodal response. In fact, in non-responders the neoadjuvant therapy is harmful, as it delays alternative, potentially effective treatment. Progression during the neoadjuvant therapy is not rare in this subset of patients.

Surgical risk models: how they contribute to improvement of our treatments?

Adverse events are common among surgical patients. The question of how to predict risk associated with invasive procedures and how to select an optimal procedure for particular patients is as old as surgery itself. Accurate calculation of complication risk and mortality risk has three important aspects: (I) Risk assessment and its discussion with a patient is essential for their informed consent to undergo surgery; (II) Determination of risk allows for implementation of specific measures, aimed at reduction of this risk; (III) Awareness of the adverse event that is likely to happen enables one to get prepared for it, to provide optimal setting for the procedure and to use appropriate treatment without delay.