Gastroenterology Education and CPD for trainees and specialists

1. Which one of the following statements regarding malignant tracheo-oesophageal fistula (MTOF) is false?

1. Evidence that stenting gives survival benefit in TOF is mixed.
2. Presence of TOF indicates stage 3 disease- FALSE
3. In cases of double stenting, airway stent should be placed first in order to avoid tracheal or bronchial compression secondary to the oesophageal stent.
4. More than 3/4th of MTOF are related to oesophageal cancer
5. Airway stent is preferred in malignant fistula developing after Ivor Lewis Oesophagectomy

Explanation :In two, large series reports, mean patient survival was reported to be 3.1-3.4 months. In one of these reports, the survival benefit was significant in patients in the stenting group (3.4 months) compared with the gastrostomy group (1.1 months), and the supportive management group (1.3 months). Once a fistula (stage T4) develops, the tumour is incurable. The treatment is palliative to alleviate symptoms. Airway stent is preferred in malignant fistula developing after Ivor Lewis Oesophagectomy (the replaced stomach or colon shows a large lumen compared with the lumen of the original oesophagus). The larger lumen makes oesophageal stent migration (and hence uncovering fistula) easier. Approximately 77% of MTOF are related to oesophageal cancer, whereas approximately 16% originate from a primary lung neoplasm.

2. Which one of the following statements regarding malignant tracheo-oesophageal fistula (MTOF) is true

1. Common symptom is haemoptysis
2. Mean survival is 11.3 months
3. Water contrast swallow should be obtained to confirm the sealing of the fistula- TRUE
4. It occurs in 40% patients of oesophageal malignancy
5. Approximately 30% of MTOF are related to oesophageal cancer

Explanation :A history of repeated coughing associated with eating, drinking, or both, with an increase in dysphagia and dyspnea are highly suggestive of a fistula In two, large series reports, mean patient survival was reported to be 3.1-3.4 months. Oesophageal stent completely seals off the fistula in 60-100% of cases. Incomplete closure of the fistula caused by spillage of material through a gap between the proximal stent margin and the oesophageal wall (‘funnel phenomenon’). This is difficult to manage despite the insertion of additional stents or glue injection to seal the gap. An additional airway stent is usually required. Thus, a contrast swallow is obtained immediately after stent insertion to confirm the sealing of the fistula and subsequently allow a patient to eat a soft diet. If there is persistent leakage through the fistula, resulting from an incomplete stent expansion, a follow-up contrast swallow should be obtained 2-3 days after stent placement in order to confirm stent expansion before food intake is resumed. Tracheo-oesophageal fistula develops in approximately 5%–15% of patients with an oesophageal malignancy and in less than 1% of those with bronchogenic carcinoma. Approximately 77% of MTOF are related to oesophageal cancer, whereas approximately 16% originate from a primary lung neoplasm

Gastroenterology training and education

MCQ On Malignant TOF

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