Stent-associated esophagorespiratory fistulas: incidence and risk factors

Published:December 13, 2012DOI:https://doi.org/10.1016/j.gie.2012.10.004

      Background

      Esophageal self-expandable stents (SESs) effectively treat strictures and leaks but may be complicated by a stent-associated esophagorespiratory fistula (SERF). Little is known about SERFs.

      Objective

      To determine the incidence, morbidity, mortality, and risk factors for SERF.

      Design

      Retrospective case-control study.

      Setting

      Single referral center.

      Patients

      All adults undergoing esophageal SES placement during a 10-year period.

      Intervention

      Stent placement.

      Main Outcome Measurements

      Occurrence of SERF, morbidity, and mortality.

      Results

      A total of 16 of 397 (4.0%) patients developed SERF at a median of 5 months after stent placement (range 0.4-53 months) including 6 of 94 (6%), 10 of 71 (14%), and 0 of 232 (0%) of those with lesions in the proximal, middle, and distal esophagus, respectively (overall P < .001). SERF occurred in 10% of those with proximal and mid-esophageal lesions, including 14% with benign strictures, 9% with malignant strictures, and none with other indications for SES placement (P = .27). The risk was highest (18%) in patients with benign anastomotic strictures. Risk factors for development of SERF included a higher Charlson comorbidity index score (odds ratio [OR] 1.47 for every 1-point increase; P = .04) and history of radiation therapy (OR 9.41; P = .03). Morbidity associated with SERF included need for lifelong feeding tubes in 11 of 22 (50%) and/or tracheostomy or mechanical ventilation in 5 of 22 (23%). Median survival after diagnosis was 4.5 months (range 0.35-67), and 7 patients survived less than 30 days.

      Limitations

      Retrospective design, limited statistical power.

      Conclusion

      SERF is a morbid complication of SES placement for strictures of the proximal and mid-esophagus. The dominant risk factors for development of SERF are prior radiation therapy and comorbidity score.

      Abbreviations:

      ERF (esophagorespiratory fistula), SERF (stent-associated ERF), SES (self-expandable stent)
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