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Laparotomy enables retrograde dilatation and stent placement for malignant esophago-respiratory fistula

DOI: 10.1186/1477-7819-6-8

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We report a patient in whom with local recurrence of esophageal carcinoma an esophagotracheal fistula occurred. Initially the patient had undergone esophageal resection with interposition of a gastric tube. Due to complete obstruction of the lumen by recurrent tumor conventional transoral stent placement failed. For retrograde dilatation a laparotomy was performed. Via a duodenal incision endoscopic access to the gastric tube was achieved. Using a guidewire the esophageal obstruction was traversed and dilated. Then it was possible to place an esophageal stent via an antegrade approach.Open surgery enables a safe access for retrograde endoscopic therapy in patients who had undergone esophageal resection with gastric interposition.Esophageal cancer is an aggressive tumor with unfavorable prognosis. Despite the radical surgery, local recurrence occurs in up to 21% of the cases [1]. Dysphagias as well as esophago-respiratory fistulae (ERF) are predominant symptoms of local tumor recurrence and represent devastating and life threatening complications. Patients are often unable to swallow food or even their own saliva without aspiration. Unless sufficient palliation is instituted rapidly, the usual cause of death is pulmonary sepsis resulting from chronic aspiration. Since covered and self expandable stents have been introduced, successful palliation has been reported in most patients[2,3]. The endoscopic management of malignant obstruction and ERF is technically challenging and requires careful endoscopic dilatation with wire guided dilators. Despite of sophisticated endoscopic strategies in some patients the passage of a guide wire is technically impossible due to a completely obstructed lumen. In this situation retrograde endoscopic dilatation via a radio guided percutaneous gastrostomy is a second option[4].However in patients who underwent esophageal resection and transformation of the stomach into a small gastric tube for esophageal reconstruction, retrograde access


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