By sealing the fistula, a successful endoscopic esophageal intubation ends the severe respiratory contamination and the inability to swallow, improving the quality of life and survival period. After the procedure, it is the malignant tumor and not the fistula that determines the future of the patient.

These tumors seem to be specific forms of esophageal cancers. For a better quality of life and longer survival time for these patients, there should be earlier diagnosis and endoscopic intubation as the best palliative treatment should be performed.

The results show that LC is a safe procedure in well-compensated Child A and B cirrhotic patients. Although hepatic cirrhosis greatly increases the surgical risks, as well as the likelihood of complications, and it also necessitates longer operative time and longer hospital stay, it is recommended that cirrhotic patients with symptomatic cholelithiasis should clearly be operated on.

Esophago-respiratory fistulas, evolving as a result of esophageal tumors, are serious and lethal complications on account of the constant respiratory contamination and the inability to swallow. They can develop either as the complication of the end stage disease or sometimes even in the first stage of the malignancy. The objective was to reveal the characteristics of the disease. In a prospective single-center study in the period between 1984 and 2004, 243 fistulas were diagnosed. Their data were analyzed using multivariate analysis. The mean age of patients with fistula was 56.9 years, the male-to-female ratio was 4.3:1. The average time of the complaints was 5.2 months, while the time of manifestation of the fistula was 7.5 months. Dysphagia was diagnosed in 97.5% of the patients, fever in 36.9%, and cachexia in 59.5%, respectively. The average loss of weight was 10.4 kg and the average size of the tumor was 7.7 cm. Endoscopic intubation was performed in 176 cases. The average survival was 3.4 months. Patients with fistula were divided into two groups, where the characteristics of the disease were significantly different. Only in 66.3% was the fistula a late complication. In the other 33.7% of the cases the fistula was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival were shorter.

The most effective way of palliation of esophagorespiratory fistulas is finding the most appropriate procedure that adapts to the given morphological situation.We would like to thank Dr Kotsis for his interest and the reflection [1] on our study [2]. The pallation of esophagorespiratory fistulas is a huge challenge since a double problem needs to solved. It is not only necessary to seal the fistula but also to restore the ability to swallow. In our opinion the main question is not to determine the best way of stenting but to find the one that adapts best to the given morphological situation. This is the key to success. In our practice both the push-through and the pull-through techniques have been used. The endoscopic method has overtaken the operative way because of its benefits, but there is still a number of situations when the latter is the method of choice. In our experience the self-expanding metal stents have met the necessary requirements more frequently than the rigid tubes. The selection of the appropriate type and size of the prosthesis needs to be individual. The stents must be covered. In our study the pathological communication was sealed by esophageal intubation in 76.6% of the cases. Endobronchial or tracheobronchial stent implantation could also give an additional opportunity, but this method was not used in our patients mainly because of the lack of proper conditions. In 72 cases stent implantation was impossible to be carried out. The reasons were: 24 total obstructions, 18 too high strictures, 4 outer compressions, 5 mild strictures (not able to keep the prosthesis in place), 9 necrotizing tumorous cavities, 3 angulations and axis deviations, 7 very poor general states, and 1 refusal. In these cases there was no chance a successful palliation of esophagorespiratory fistulas which determined their survival and quality of life. There has also been a number of further palliative treatment possibilities (restenting, laser, etc.) for these patients, but the deterioration of their clinical status has prevented their use. Cuffed funnel tubes or double cuffed tubes give additional opportunities, especially in the management of the wide hollow necrotizing tumorous cavities. In our opinion the use of covered self-expanding stents in esophagorespiratory fistulas is treatment of choice and the new types of prostheses seem to promising. References[1] Kotsis L. What is the most effective palliation for esophagorespiratory fistulas? Eur J Cardiothorac Surg 2009;36:225.[2] Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period.