Study Of The Clinical Manifestation Of Thoracostomach-tracheal (Bronchial) Fistulas And Its Imaging Diagnosis

Background and objectiveSurgical resection is the preferred treatment method for early and middle stage esophageal carcinoma.Complete tumor resection and thorough cleaning of surrounding lymph nodes are the principles of surgery.After the surgery,the stomach is lifted to the chest and made to locate in the original esophageal bed area in posterior mediastinum to reconstruct the upper digestive tract mainly through aortic arch anastomosis or cervical esophagogastrostomy.However,because of changes in anatomical position,blood supply and innervation of the stomach,as well as possible surgical injury,postoperative residual tumor,neoplasm recurrence,incomplete treatment method,additional chemoradiotherapy and others,the occurrence of some complications that are closely related to thoracostomach is inevitable.Thoracostomach-tracheal(bronchial)fistula is one of the most severe postoperative complications.The incidence of it is about 0.2%~1.9% and the prognosis of it is poor once it occurs.In the past,due to insufficient understanding of the disease and limited diagnostic techniques,missed diagnosis or misdiagnosis as epiglottic dysfunction,deglutition disorder,radiation pneumonitis,esophagotracheal fistula and others could easily occur,resulting in delayed treatment.In recent years,along with the wide application of esophageal carcinoma surgery,especially the additional stereoscopic radiotherapy(accurately-positioned intensity modulated radiotherapy,X knife,? knife,etc.)after the surgery on residual tumors in esophageal bed area,thoracostomach in esophageal bed area receives too much radiation,resulting in increasingly higher incidence of thoracostomach-tracheal(bronchial)fistula.Early diagnosis as well as timely and accurate treatment are essential in increasing cure rate and reducing mortality rate.By carrying out a retrospective analysis on the clinicopathological data of 729 patients who underwent esophagogastrostomy after radical resection of esophageal carcinoma,the paper aims to explore the risk factors for thoracostomach-tracheal(bronchial)fistula after esophageal carcinoma surgery;the clinicopathological data of 162 patients with thoracostomach-tracheal(bronchial)fistula are retrospectively analyzed to summarize its distinctive clinical manifestations and investigate the clinical value of MSCT in diagnosing the disease in order to provide guidance for early diagnosis and prognosis of thoracostomach-tracheal(bronchial)fistula.Materials and methods:The study retrospectively analyzes 729 esophageal carcinoma patients who received treatment at the Thoracic Surgery Department of the First Affiliated Hospital of Zhengzhou University from January,2011 to December,2016.All patients received esophagogastrostomy after radical resection of esophageal carcinoma.The clinicopathological data of these patients are recorded to explore the risk factors for postoperative thoracostomach-tracheal(bronchial)fistula.The study retrospectively analyzes 162 thoracostomach-tracheal(bronchial)fistula patients who received treatment at the Intervention Department of the First Affiliated Hospital of Zhengzhou University from January,2011 to December,2016.All patients had a history of esophageal carcinoma surgery.Aortic arch anastomosis or cervical esophagogastrostomy was performed after the surgery to reconstruct the upper digestive tract.All patients were diagnosed with thoracostomach-tracheal(bronchial)fistula through chest multi-slice spiral CT(MSCT),fiber gastroscope or fiber bronchoscope,and DSA with oral water-soluble medium and other imaging examinations.No mediastinum infection occurred.The clinical manifestations and examining results of different imaging technologies after the onset of the disease are recorded for corresponding statistical analysis.Results:1.Surgeries were performed successfully on all 729 esophageal carcinoma patients with 257 cases of thoracotomy and 472 cases of thoracoscopic surgery;tumor locations: 128 cases in upper esophagus,426 cases in middle esophagus,and 175 cases in lower esophagus;postoperative pathology results: 695 cases of squamous carcinoma,7 cases of adenocarcinoma,and 27 cases of other types of carcinoma;thoracostomach-tracheal(bronchial)fistula occurred in 16 cases(2.19%).Single factor analysis results show that gender,age,history of diabetes,preoperative radiotherapy,postoperative pulmonary infection,and postoperative additional radiotherapy are risk factors for thoracostomach-tracheal(bronchial)fistula after esophageal carcinoma surgery;multi-factor analysis results show that preoperative radiotherapy,postoperative pulmonary infection,and postoperative additional radiotherapy are independent risk factors for thoracostomach-tracheal(bronchial)fistula after esophageal carcinoma surgery.2.In 162 patients with thoracostomach-tracheal(bronchial)fistula,there are 130 male patients(80.25%)and 32 female patients(19.75%)with a mean age of(59.17±9.12)years old(range 32~74 years);and 145 patients(89.51%)are older than 50.3.In 123 patients who received postoperative radiotherapy,116 patients(94.31%)suffered from the attack of the disease within one year,and the peak of incidence is about one month after the radiotherapy.4.In 162 patients,147 patients(90.74%)showed different degrees of increase in body temperature with a fluctuation from 37.5 to 39.8 ? ?;135 patients(83.33%)showed signs of pulmonary refractory infection;27 patients(14.20%)had dyspnea and need continuous low flow oxygen uptake;15 patients(9.25%)had nutritional failure.5.All patients suffered from burning-like irritating cough which cannot be cured simply through fasting and water deprivation.The cough worsened in supine position and eased in sitting or half-sitting position.Suppressing gastric juice secretion and extracting gastric juice by exerting continuous negative and decompressed pressure on gastric cavity intubation could effectively alleviate the cough.6.In 162 patients,153 patients(94.44%)were detected to be positive through DSA with oral water-soluble medium,151 patients(93.21%)were detected to be positive through MSCT,and 160 patients(98.77%)were detected to be positive through MSCT and DSA.Combing the examining results of MSCT,DSA and endoscopy,the specific position and type of fistula could be clear: 24 cases(14.82%)of thoracostomach-tracheal fistula;37 cases(22.85%)of thoracostomach-carina fistula;39 cases(24.07%)of thoracostomach-left main bronchial fistula;7 cases(4.32%)of thoracostomach-left upper lobe bronchial fistula;4 cases(2.47%)of thoracostomach-left lower bronchial fistula;32 cases(19.75%)of thoracostomach-right main bronchial fistula;6 cases(3.70%)of thoracostomach-right upper lobe bronchial fistula;7 cases(4.32%)of thoracostomach-right middle lobe bronchial fistula;3 cases(1.85%)of thoracostomach-right lower lobe bronchial fistula;3 cases(1.90%)of complex fistula.Conclusion:1.Preoperative radiotherapy,postoperative pulmonary infection,and postoperative additional radiotherapy are independent risk factors for thoracostomach-tracheal(bronchial)fistula after esophageal carcinoma surgery.2.Aged males are more likely to suffer from thoracostomach-tracheal(bronchial)fistula.The disease mostly occurs within one year of radiotherapy.3.Thoracostomach-tracheal(bronchial)fistula has a distinctive clinical manifestation,namely,“Decubitus Position Burning-like Irritating Cough Syndrome ”.4.MSCT,which can show orificium fistulae and fistulous tract clearly,can aid the typing of fistulas.It can be the preferred method for diagnosis and confirmed diagnosis of the disease.