Surgical strategy for the treatment of aortoesophageal fistula

Aorto-esophageal Fistula Management

Aorto-esophageal fistula is a rare but life-threatening source of massive upper gastrointestinal bleeding. Prompt diagnosis and intervention are key for patient survival. Treatments consist of aortic resection, thoracic endovascular aortic repair, esophagectomy with diversion, and primary esophageal repair. The appropriate treatment is dependent on patient hemodynamics and fitness and familiarity with operative approaches by the treating team.

Surgical treatment of graft infection combined with aortoesophageal fistula after TEVAR: a retrospective single-center, single-arm study

OBJECTIVE

Aortoesophageal fistula (AEF) secondary to thoracic aortic endovascular repair (TEVAR) is rare and fatal. The author reports the treatment methods and outcomes of 10 patients with a TEVAR graft infection and an aortoesophageal fistula.

METHOD

A retrospective analysis was conducted on the clinical data of 10 patients who developed a secondary AEF and a graft infection after TEVAR from March 2018 to March 2024.

RESULT

The perioperative mortality rate was 70%. Two patients had TEVAR only and all died of bleeding and infection. Eight patients underwent open surgery, five died within 30 days, four of them died due to massive bleeding, the one patient died of a serious infection after surgery. Three patients recovered well and were discharged. One patient died of severe pneumonia 3 months after discharge, and two patients survived for 6 years and 3 months, respectively.

CONCLUSION

Extra-anatomical bypass reconstruction is feasible for treating graft infection combined with aortoesophageal fistula after TEVAR but related to bad outcomes in most of the patients. It is reserved for highly select patients and is performed at centers with experience with this procedure.

Two-Step Operation for Aortoesophageal Fistula After Thoracic Endovascular Repair

Aortoesophageal fistula (AEF) caused after thoracic endovascular aortic repair (TEVAR) is rare but a serious complication. We report a successful staged operation for AEF after TEVAR. A 70-year-old male underwent TEVAR for a ruptured aneurysm of the descending aorta and subsequently developed AEF three months later. First, the patient underwent the resection of the esophagus, which was the focus of the infection under the right thoracoscopic approach. Second, descending aorta replacement was performed using a left thoracotomy approach. The patient has been well for about two years since the second operation without recurring graft infection. Staged operation with a different approach to the infection zone is a useful method for AEF.

Combined Endovascular and Endoscopic Management of a Secondary Aortoesophageal Fistula after Open Surgical Aortic Repair in a Giant Descending Thoracic Aortic Pseudoaneurysm: Case Report and Review of Literature

Secondary aortoesophageal fistula (AEF) is defined as a communication between the aorta and the esophagus, occurring after aortic disease treatment or esophageal procedures, associating very high mortality rates with treatment and being fatal without it. Several treatment strategies have been described in the literature, combining open surgery or endovascular aortic repair with surgical or endoscopic management of the esophageal lesion. We present the case of a 53-year-old patient with a history of open aortic surgery for a giant descending thoracic aortic pseudoaneurysm complicated with secondary AEF, successfully managed using emergency transiliac TEVAR (thoracic endovascular aortic repair), extensive antibiotic therapy associated with nutritional replenishment, and rehabilitation therapy. Novel endovascular and endoscopic devices have been developed, offering less invasive treatment strategies with improved outcomes, especially for high risk surgical patients. This case highlights the importance of a multidisciplinary approach to personalized medicine to manage such complex situations.

Management of aortoesophageal fistula primarily using esophageal preservation

Objective

Aortoesophageal fistula is a rare, life-threatening condition. There is no consensus regarding the surgical management of the esophagus in this condition.

Methods

We retrospectively evaluated 13 patients diagnosed with aortoesophageal fistulas at a single institution from 2003 to 2021. Descriptive statistics were used to analyze patient characteristics, operative characteristics, and patient outcomes. Kaplan-Meier survival analysis was performed.

Results

Patients' mean age was 63.5 years, and 6 (46.2%) were female. The most common presenting symptoms were hemoptysis/hematemesis (69.2%), chest/back pain (46.2%), and fever (38.5%). Twelve patients (92.3%) had a history of aortic procedures. The median time between the index operation and repair of the secondary aortoesophageal fistula in the 12 patients was 5 months. The index operation was a thoracic endovascular aortic repair in 10 of 12 patients (83.3%). Eleven patients (84.6%) underwent primary esophageal repair with flap coverage (omentum or muscle). One of these patients needed an esophagectomy within 1 year. The primary surgical management of the aorta was graft excision and replacement, aside from 1 patient who underwent primary repair. The 30-day survival was 69.2%, and 1-year and 5-year survivals were 31.7%. There were no recurrent infections at the esophageal fistula site.

Conclusions

Aortoesophageal fistula remains a rare condition, but its case numbers have increased with thoracic endovascular aortic repair. It continues to be a difficult condition to manage and has a high fatality rate. Esophageal-preserving surgery may be a safe and less-invasive option for patients with a small defect.

Vascular covered stent and video-assisted thoracoscopic surgery for Aortoesophageal fistula caused by esophageal fishbone: a case report

BACKGROUND

Aortoesophageal fistula (AEF) is a rare condition characterized by communication between the aorta and esophagus. AEF caused by an esophageal foreign body is even rare, and there is currently no recommended standard treatment protocol. We report a case of delayed aortic rupture after the endoscopic removal of a fish bone, which was successfully treated with a combined approach of vascular stenting and thoracic surgery.

CASE PRESENTATION

A 33-year-old man presented to the hospital after experiencing chest discomfort for 3 days following the accidental ingestion of a fish bone. Under endoscopic guidance, the fish bone was successfully removed, and the patient was subsequently admitted for medical therapy. On the fourth postoperative day, the patient suddenly developed hematemesis, and chest computed tomography angiography revealed the presence of an AEF. This necessitated urgent intervention; hence, thoracic surgery was performed and a vascular-covered stent was placed. Following the surgical procedure, the patient received active medical treatment, recovered well, and was successfully discharged from the hospital.

CONCLUSIONS

In patients with esophageal perforation caused by foreign bodies, hospitalization for observation, computed tomography angiography examination, early use of antibiotics, and careful assessment of aortic damage are advised. Thoracic endovascular aortic repair and esophageal rupture repair may have benefits for the treatment of AEF.

A successful endovascular aortic repair of aortoesophageal fistula following esophagectomy: a case report and literature review

BACKGROUND

Aortoesophageal fistula (AEF) is an extremely rare and highly fatal complication leading to a high risk of morbidity and mortality. Successful management of AEF after esophagectomy for esophageal carcinoma has rarely been reported in the literature.

CASE PRESENTATION

Here we present a rare case of a 44-year-old female with complications of AEF after esophagectomy for esophageal carcinoma, mainly presented as vomiting of blood. Both computed tomographic and computed tomography angiography of the chest showed bilateral pleural effusion and atelectasis, while gastroscopy showed large gastrointestinal bleeding. Emergency surgery was performed that included the removal of the mediastinal abscess, left lower pulmonary wedge resection, and thoracic endovascular aortic repair (TEVAR), followed by supportive treatment. The surgery went successful, and the patient was followed up for 1 year after discharge and showed good recovery. We also reviewed previous literature on the history, causes, pathophysiology, clinical presentation, diagnosis, and treatment of AEF after esophagectomy for esophageal adenocarcinoma.

CONCLUSIONS

In our case, thoracotomy combined with TEVAR was effective in treating AEF after esophagectomy for esophageal adenocarcinoma. This case provides successful experiences for clinical diagnosis and treatment of AEF after esophagectomy for esophageal carcinoma.

Successful management following combined thoracic endovascular aortic repair and minimally invasive esophagectomy for primary aortoesophageal fistula: A case report

Aortoesophageal fistula (AEF) is a rare but life-threatening pathology. We report a case of a primary AEF that was successfully managed with temporary thoracic endovascular aortic repair (TEVAR) and esophagectomy with video-assisted thoracoscopic surgery. A 73-year-old man was transferred to the emergency department with a complaint of hematemesis. A computed tomography scan identified an AEF due to aortic aneurysm. We placed a stent using TEVAR for the purpose of hemodynamic stasis, and the operation was performed 23 h after admission. Right video-assisted thoracoscopic esophagectomy (VATS-E) was chosen, and a cervical esophagostomy and a feeding gastrostomy tube was constructed. Infection had been effectively controlled postoperatively. Four months after the first operation, we performed esophageal reconstruction. At the 70-month follow-up examination, the patient had no signs of mediastinitis. VATS-E immediately after hemostabilization by TEVAR is useful management for primary AEF.

Life-threatening gastrointestinal bleeding caused by perforation of a penetrating atherosclerotic ulcer into the esophagus

We present a case of life-threatening gastrointestinal bleeding caused by a penetrating atherosclerotic ulcer (PAU) that ruptured into the esophagus. A 65-year-old man presented with pyrexia and nausea. Contrast-enhanced computed tomography (CT) performed on admission revealed a hematoma between the lower esophagus and descending aorta due to a contained rupture of a PAU, which was undiagnosed at that time. Esophagogastroduodenoscopy (EGD) performed on the fifth day of admission revealed a subepithelial lesion in the lower esophagus, further complicated by ulcer formation. Biopsy did not reveal any malignant findings. On the eighth day of admission, the patient experienced substantial hematemesis with vital signs indicative of shock. Emergency EGD was performed, which revealed life-threatening bleeding in the lower esophagus. Contrast-enhanced CT revealed an aortoesophageal fistula with massive hematemesis, after which the patient died. An autopsy revealed perforation of the PAU into the esophagus without aortic dissection or a true aneurysm.Patients with atherosclerosis who develop recent-onset gastrointestinal symptoms, progressive anemia, and/or periaortic lesions should be carefully evaluated using contrast-enhanced CT, and PAU should be considered in the differential diagnosis.

Refractory esophageal-mediastinal fistula successfully treated with endoluminal vacuum therapy and enteral nutrition using a double-lumen elemental diet tube: a case report

BACKGROUND

Aortic-esophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR) has a high fatality rate and is difficult to treat. Endoluminal vacuum therapy (EVT) has recently appeared and proven to be a useful method for anastomotic leakage.

CASE PRESENTATION

A 76-year-old man underwent aortic arch replacement for a stent graft infection after TEVAR. Persistent mediastinitis and pyothorax were observed after aortic arch replacement, and further examination revealed an esophageal-mediastinal fistula (EMF). Over-the-scope clip (OTSC®) closure was performed to treat EMF but achieved no cure. Then, the patient was referred to our hospital. First, we removed the OTSC® that interfered with the treatment using the remOVE System® and started EVT using a double-lumen elemental diet tube (W-EDT®). The vacuum sponge was affixed to the vacuum side of W-EDT®, and enteral nutrition administered through W-EDT was combined with EVT. EMF was cured 11 days after EVT, and the patient was able to feed himself.

CONCLUSION

The combination of EVT and enteral nutrition feeding using W-EDT® is a successful novel procedure to treat refractory EMF.

Aortoesophageal fistula treated using one-stage total reconstruction: a case report from a high-volume center

BACKGROUND

Aortoesophageal fistula (AEF) is a rare but typically life-threatening condition. Although several treatment strategies exist, including conservative treatment with intraluminal stent graft and open thoracic aortic replacement, the overall outcome remains poor, ranging from 16 to 39%. Furthermore, esophageal reconstruction methods vary between hospitals. Herein, we report a case of aortoesophageal fistula treated using one-stage total reconstruction.

CASE PRESENTATION

This case involved a 58-year-old woman who developed acute type A aortic dissection and underwent successful total arch replacement at the other hospital. However, she developed AEF 1 year later and underwent urgent thoracic endovascular aortic repair, which eventually failed. We performed thoracic aortic replacement, total esophagectomy, gastric tube reconstruction, and omental flap in a one-stage operation. The patient was extubated the next day and transferred to the general ward on postoperative day 3. Computed tomography revealed favorable results.

CONCLUSIONS

For postoperative AEF, dedicated debridement with reconstruction is more effective than conservative treatment. In an experienced center, post-procedure-related AEF can be easily treated using one-stage reconstruction.

Surviving the nonsurvivable combination of a mycotic aneurysm progressing into a concomitant aorto-bronchial- and aorto-esophageal fistula, a case report

BACKGROUND

Aortic mycotic aneurysms are a rare but life-threatening condition and may be associated with aorto-bronchial- and aorto-esophageal fistulas. Although both very rare, they carry a high mortality and require (urgent) surgical intervention. Surviving all three conditions concomitantly is extraordinary. We describe a patient who underwent staged repair of such combined defects.

Giant Patent Ductus Arteriosus Aneurysm Compressing the Esophagus

It is extremely rare to observe aneurysmal changes in patients with patent ductus arteriosus (PDA), especially in adults. If left untreated, a PDA aneurysm can increase the risk of life-threatening complications, including rupture, dissection, esophageal fistula, and infection. Following is a description of successful surgical repair in a 55-year-old man with PDA aneurysm compressing the esophagus. Histologically, the aneurysmal wall showed mild thickening of the intima and media with hyperplastic smooth muscle cells, but no destructive changes were observed.

Esophageal reconstruction as the first step for treating secondary aortoesophageal fistula due to thoracic endovascular aortic stent infection

BACKGROUND

The surgical strategy for aortoesophageal fistula (AEF) depends on the experience of each surgeon, and there is no consensus on the strategy to be adopted. We propose our two-stage operation compromising esophagectomy and reconstruction as the first step and in situ aortic graft replacement as the second step after 7 days for treating AEF secondary to thoracic aortic stent graft infection.

CASE PRESENTATION

A diagnosis of AEF was made in a 70-year-old man with a history of multiple aortic interventions. The patient underwent esophageal resection and reconstruction with a pedicled stomach roll endoscopically in the right thoracic cavity. Postoperatively, enteral feeding was resumed via a feeding tube placed in the jejunum to maintain adequate nutritional status. There was no evidence of either anastomotic leakage or necrosis. Seven days later, the patient underwent removal of the infected stent graft and in situ graft replacement via a redo left thoracotomy. After the surgery, the patient was able to start oral intake relatively early. Although more than 6 months has passed since the patient was discharged, no recurrence of infection has been observed.

CONCLUSIONS

The benefit of our strategy is the radical treatment for secondary AEF and the early resumption of oral intake.

AORTO-ESOPHAGEAL FISTULA SECONDARY AFTER THORACIC ENDOVASCULAR AORTIC REPAIR

Aortoesophageal fistula (AEF) secondary to thoracic endovascular aortic repair (TEVAR) is a rare clinical entity that poses a threat to life as it causes massive digestive bleeding, and it is estimated that 60% of patients who suffer from it could die within within 6 months of the onset of their symptoms. It requires a high clinical suspicion to establish an early multidisciplinary surgical treatment. We present the cases of two patients diagnosed with aortoesophageal fistulas after TEVAR in the last 5 years (January 2018-December 2022) while reviewing the existing scientific literature on the matter.

A New Mini-Invasive Approach for a Catastrophic Disease: Staged Endovascular and Endoscopic Treatment of Aorto-Esophageal Fistulas

Aorto-esophageal fistula (AEF) is an uncommon but usually fatal disorder. Surgery with resection of an aneurysm and esophagus, in situ reconstruction of the descending aorta and omental flap installation offers the gold standard for the reduction of infections, but it is burdened by high intraoperative and perioperative mortality rates. We report our experience with a combined minimally invasive approach for the multi-stage treatment of three cases of aorto-esophageal fistula caused by thoracic aneurysm rupture. In all of the patients, the aneurysm was treated with thoracic endovascular aortic repair and the esophageal lesion was treated with esophageal endoprosthesis placement. According to our experience, the combined strategy of thoracic endovascular aortic repair (TEVAR) and esophageal less invasive endoscopic treatments represents an alternative solution in frail patients with high surgical risk.

A word of caution: bilateral axillofemoral bypass could not provide sufficient blood flow in a patient who underwent aortic resection for aortoesophageal fistula: a case report

An 81-year-old man was transferred to our hospital for a ruptured infected descending aortic aneurysm. An emergency thoracic endovascular aortic repair was performed, but a computed tomography scan 7 days later revealed an aortoesophageal fistula. The establishment of extracorporeal circulation using the femoral artery and utilization of the omentum was considered difficult. We performed bilateral axillofemoral bypass followed by descending aortic resection and esophagectomy. However, the patient’s circulatory insufficiency worsened, and he died on the 18th postoperative day.

In the treatment of aortoesophageal fistula, bilateral axillofemoral bypass is not recommended as an alternative to descending aortic replacement.

The impact of vascularized tissue flap coverage on aortic graft infection with and without infected graft excision

OBJECTIVES

Aortic graft infection (AGI) is a serious condition associated with a high mortality rate. However, optimal surgical options have not been identified. Therefore, we retrospectively reviewed AGI cases, including those in the thoracic and abdominal regions, with or without fistula formation, to investigate the various options for better outcomes.

METHODS

We reviewed 50 patients who underwent surgical interventions for AGI out of 97 patients with arterial infective disease. The mean patient age was 67 ± 17 years. Fourteen patients (28%) had a fistula with the gastrointestinal tract or lung. A combination of graft excision and vascularized tissue flap coverage was performed in 25 cases (50%). Tissue flap alone, graft excision alone and cleansing alone were performed in 9 (18%), 10 (20%), and 6 cases (12%), respectively.

RESULTS

Total in-hospital mortality rate was 32% (n = 16). In-hospital mortalities in patients with and without fistulas were 43% (6/14) and 28% (10/36), respectively (P = 0.33). Subgroup analysis among patients without fistula demonstrated that the in-hospital mortality rate of the patients with vascularized tissue flap (3/21, 14%) was significantly lower than that of the patients without vascularized tissue flap (7/14, 50%, P = 0.026). Overall 1- and 5-year survival rates were 66% and 46%, respectively. In multivariable analysis, an independent factor associated with in-hospital mortality was vascularized tissue flap (odds ratio 0.20, P = 0.024).

CONCLUSIONS

Vascularized tissue flaps could provide better outcomes for AGI. Graft preservation with vascularized tissue flaps could be a useful option for AGI without fistula.

[Aortoesophageal fistula-A rare differential diagnosis of upper gastrointestinal bleeding]

Approximately 1% of all patients are admitted to an emergency room for upper gastrointestinal hemorrhage. Differential diagnostics reveal an aortoesophageal fistula (AEF) as the cause of the bleeding in very few cases. Despite increasing means of diagnostics and treatment, mortality is high in patients with AEF even under maximum medical care. These are often fulminant situations with fatal outcome for the patient. We report a case that supports this observation described from previous cases and give a closer look at this rare emergency situation. A 54-year-old patient was taken to a maximum care hospital with the clinical diagnosis of upper gastrointestinal bleeding after receiving emergency medical treatment. The source of bleeding was quickly identified as an AEF following lobectomy for bronchial cancer. Despite maximum interventional intensive treatment, the patient died a few hours after hospital admission in hemorrhagic shock due to fulminant hemorrhage from the fistula.

Risk Factors for Mortality in Patients with Aortoesophageal Fistula Related to Aortic Lesions

Objective

Aortoesophageal fistula (AEF) related to aortic aneurysm and dissection is an uncommon but life-threatening condition. We performed a systematic review of risk factors for mortality and factors associated with the prognosis of AEF.

Methods

A systematic search of the PubMed, Embase, and Cochrane Library databases was performed. Clinical characteristics, diagnostic methods, and treatments were assessed in terms of their ability to predict mortality.

Results

The systematic review identified 184 eligible articles including 219 patients with AEF. Multivariable Cox regression revealed positive correlations of hemorrhagic shock (hazard ratio (HR): 1.824, 95% CI: 1.217-2.735, P = 0.004), sepsis (HR: 1.714, 95% CI: 1.112-2.641, P = 0.015), multiorgan failure (HR: 3.060, 95% CI: 1.470-6.368, P = 0.003), and conservative treatment (HR: 5.257, 95% CI: 3.405-8.116, P < 0.001) with mortality and a negative correlation between combination therapy (aortic graft replacement and esophagectomy) and mortality (HR: 0.319, 95% CI: 0.125-0.813, P = 0.017). Kaplan–Meier survival analysis showed that the 1-year cumulative survival rate was 42.5 ± 3.8%. The overall fistula-related mortality rate was 47.0% (103/219). The most common causes of death were bleeding (54.9%) and infection (29.2%).

Conclusions

We found that hemorrhagic shock, sepsis, and multiorgan failure were risk factors for death in patients with AEF. Additionally, conservative treatment was associated with a higher rate of mortality, while combined aortic graft replacement and esophagectomy improved the prognosis.

Surgical treatment for secondary aortoesophageal fistula after prosthetic aortic replacement: A report of four cases

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Secondary aortoesophageal fistula (AEF) after aortic prosthetic replacement is rare, so there have been few reports assembling multiple cases.

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AEF is difficult to diagnose early if there is little experience, and hence is associated with high mortality and morbidity rates.

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The strategy involving stepwise surgery in coordination with infection control and general health improvement was attempted in our facility.

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From our observations, this approach appears to be a valid strategy for secondary AEF after aortic prosthetic replacement.

Introduction

With the increase of thoracic aortic aneurysm surgery and thoracic endovascular aortic repair, secondary aortoesophageal fistula (AEF) has been reported. However, the treatment strategy for AEF remains controversial.

Presentation of cases

Four patients who had undergone prosthetic aortic replacement for thoracic aortic aneurysm 4–36 months previously, were hospitalized with sepsis-like symptoms. They were diagnosed with aortic prosthetic graft infection after computed tomography revealed ectopic gas around the prosthesis. After that, esophagogastroduodenoscopy revealed an esophageal perforation, so we diagnosed AEF. They received medication and stepwise surgery; 1 patient was discharged, 2 remain hospitalized, and 1 died.

Discussion

Some reports have suggested that combined surgery provides better outcomes for AEF. Infection may be controlled by esophagectomy and antibiotic treatment, so prosthesis replacement is not always necessary. However, we should note that infection between a prosthetic graft and the native aorta brings a danger of pseudoaneurysm of the anastomosis.

Conclusion

Based on our experience we conclude that surgery performed stepwise along with infection control and general health improvement is a valid treatment strategy for secondary AEF after prosthetic aortic replacement.

Fistulas between the Esophagus and Adjacent Vital Organs in Esophageal Cancer

Esophageal fistulas may occur in an advanced stage or as a potentially life-threatening complication of treatment. They can be divided into esophageal-respiratory and esophageal-aorta fistulas. The diagnosis is confirmed with fluoroscopy using dilute barium oral contrast, followed by thin-section computed tomography, which defines the precise location and extent of the fistula. Flexible esophagoscopy and bronchoscopy are required for confirmation and anatomic assessment of the suspected fistula and provide additional information for treatment planning. Contamination is traditionally controlled by surgical exclusion, along with a jejunal feeding tube. Currently, fully covered self-expanding metal stents are the primary treatment option.

Thoracic aortic aneurysm causing aorto-esophageal fistula-our experience with a rare disease

Aorto-esophageal fistula is a life-threatening condition, accounting for a small number of cases of upper gastrointestinal bleeding where patients present with one or more features of Chiari's triad. We present the case of a 43-year-old woman, referred to us with symptoms of central chest pain, sudden onset dysphagia followed by massive hemoptysis. She was diagnosed with an aorto-esophageal fistula due to a ruptured thoracic aortic aneurysm and rushed for an emergency endovascular thoracic aortic stent and feeding jejunostomy with intravenous antibiotics and supportive care. After 6 weeks of surgery, the patient was re-evaluated to plan for an esophageal stent if required. The purpose of this presentation is to make the surgical fraternity aware of the gravity of this disease and novel techniques to manage it.

[Surgical treatment of a patient with traumatic rupture of the aortic arch and late oesophageal perforation]

Described herein is a clinical case report regarding a patient presenting with traumatic rupture of the aortic isthmus with the development of a pseudoaneurysm occupying virtually the entire posterior mediastinum and measuring 20?10 cm in size. He was immediately treated as an emergency to undergo prosthetic reconstruction of the portion of the aortic arch and descending thoracic aorta by means of temporary bypass grafting with a synthetic graft in order to protect the visceral organs. The postoperative period was complicated by oesophageal perforation with the formation of an oesophago-paraprosthetic fistula, infection of the vascular graft, accompanied by the development of pleural empyema and mediastinitis. A second operative procedure was performed, consisting of subclavian-iliac bypass grafting on the right with a polytetrafluoroethylene graft measuring 20 mm in diameter, exclusion of the intrathoracic portion of the oesophagus, creation of a gastro- and oesophagostoma, retrieval of the vascular graft followed by suturing of the aorta, pleurectomy, decortication of the lung, and removal of the empyemic sac on the left. There was no evidence of ischaemia of the spinal cord or visceral arteries. One month postoperatively, he underwent a traumatological stage and 4 months thereafter plasty of the oesophagus with an isoperistaltic gastric pedicle, extirpation of the thoracic portion of the oesophagus, to be later on followed by closure of the oesophagostoma. The patient experienced no difficulties either while walking or during other physical activities, with the ankle-brachial index amounting to 0.9. With time, he developed difficult-to-correct pulmonary hypertension. Unfortunately, the patient eventually died of acute cardiopulmonary insufficiency 9 years after right-sided extra-anatomical subclavian-iliac bypass grafting.

Aorto-esophageal fistula: successful open surgical management of two cases

An aorto-esophageal fistula (AEF) is a rare yet life-threatening cause of upper gastrointestinal bleeding. We report our experience with open surgical management of two cases of AEF. Both cases presented with almost identical presentations: hematemesis and hemodynamic instability. The aorta in the first patient was normal; the defect was small and was repaired with a Dacron patch. The second patient had an aneurysmal aorta, which was replaced with a Dacron graft. Both cases were performed under partial bypass. The esophageal rent in both patients was debrided, primarily closed and buttressed with a vascularized intercostal pedicle. Nonavailability of endovascular personnel and equipment along with hemodynamic instability of the patient influenced our surgical strategy. Long-term follow-up of these patients is necessary to analyze the outcomes of our surgical repair.

Hemorrhagic Shock Secondary to Aortoesophageal Fistula as a Complication of Esophageal Cancer

Although aortoesophageal fistulas are rare, they can present as life-threatening emergencies. This condition can develop secondary to an aneurysm, foreign bodies, infiltrating tumors, and radiotherapy. We report a patient with hemorrhagic shock secondary to an aortoesophageal fistula. A 69-year-old male with squamous cell carcinoma of the esophagus treated with chemoradiation and metallic stent placement was admitted to the intensive care unit (ICU) after an episode of hematemesis. The patient was hemodynamically unstable, requiring fluid resuscitation, blood transfusions, and respiratory and vasopressor support. The patient developed electric pulseless activity, and cardiopulmonary resuscitation was performed for 40 minutes. An upper endoscopy showed the esophageal tumor infiltrating into the stent, and computed tomography (CT) angiogram showed leakage of contrast from the thoracic aorta to the esophagus. The diagnosis of aortoesophageal fistula was made. The patient underwent endovascular management for the fistula. However, his critical condition did not improve, and the patient perished.

Aortoesophageal fistula: review of trends in the last decade

We reviewed articles on aortoesophageal fistula (AEF) published between January, 2009 and December, 2018. Postoperative aortic disease was the most common cause of AEF, followed by primary aortic aneurysm, bone ingestion, and thoracic cancer. Thoracic endovascular aortic repair (TEVAR) was the most common initial therapy for primary aortic disease, rather than graft replacement. Secondary AEF developed between 1 and 268 months, and between 1 and 11 months after the initial therapy for aortic disease and thoracic cancer, respectively. TEVAR trended to be preferred over surgery for aortic lesions because of its minimal invasiveness and certified hemostasis. In contrast, esophagectomy was preferred for esophageal lesions to remove the infectious source. A combination of surgery for the aorta (TEVAR, graft replacement or repair) and esophagus (esophagectomy, esophageal stent or repair) was usually adopted. Each graft replacement or esophagectomy was associated with a favorable prognosis for aortic or esophageal surgery, and the combination of graft replacement and esophagectomy generally improved the prognosis remarkably. Antibiotic therapy was given to 65 patients, with 20 receiving multiple antibiotics aimed at strong effects and the type of antibiotic described as broad-spectrum in 29 patients. Meropenem, vancomycin, and fluconazole were the most popular antibiotics used to prevent graft or stent infection. In conclusion, graft replacement and esophagectomy can achieve a favorable prognosis for patients with AEF, but strong, broad-spectrum antibiotic therapy might be required to prevent sepsis after surgery.

First Result of a Tailored Progressive Multistep Approach for the Treatment of Aorto-esophageal Fistulae

BACKGROUND

Aorto-esophageal fistulae (AEFs) are a rare but serious and life-threatening disease of the mediastinum. Especially, AEF in the presence of infected stent grafts, for example, after thoracic endovascular aortic repair (TEVAR) is only curable by a multistage interdisciplinary surgical approach. This study presents the results of our four-stage approach consisting of bridging TEVAR, esophagectomy, complete stent removal followed by total bovine tube aortic replacement (TBTAR), and finally esophageal reconstruction.

METHODS

A case series of four patients from our department receiving a four-stage treatment of AEF is presented in this study. Retrospective database analysis focusing on overall survival, duration of intensive care unit and total hospital stay until discharge, complications, surgical time frame, and completion of chosen surgical treatment course was performed.

RESULTS

Overall, four patients surgically treated for AEF since May 2015 were included. A 30-day mortality was 0%, and overall survival at 1 year was 75%. All patients survived more than 5 months and could be discharged after TEVAR and esophagectomy. TBTAR could be performed in two of four patients (50%). Esophageal reconstruction was completed in all patients. Average follow-up was 20.3 ± 1.7 months or until death.

CONCLUSION

The acute management of AEF using this approach seems satisfactory, especially for reducing acute short-term mortality. Complete restoration of the circulatory system and digestive tract remains challenging and is associated with high morbidity. We support the application of bridging TEVAR with a staggered approach to further surgical treatment individually tailored to the patient.

Staged Surgical Treatment of Primary Aortoesophageal Fistula

Aortoesophageal fistula (AEF) is a rare and potentially fatal disease that causes massive gastrointestinal bleeding. Therefore, early diagnosis and treatment are essential to prevent mortality. Controlling the massive bleeding is the most important aspect of treating AEF. The traditional surgical treatment was emergent thoracotomy, but intraoperative or perioperative mortality was high. We report a case of a patient presenting with hematemesis who was successfully treated by a staged treatment, in which bridging thoracic endovascular aortic repair was followed by delayed surgical repair of the esophagus and aorta.

Complex two-stage open surgical repair of an aortoesophageal fistula after thoracic endovascular aortic repair

Aortoesophageal fistula after thoracic endovascular aortic repair is a rare but fatal complication, and no clear guidelines exist in the literature for optimal management. Herein, we report a complex case of a patient with an infected thoracic endograft that led to an aortoesophageal fistula. The treatment comprised a two-stage open surgical approach-an extra-anatomic aortic bypass in the first stage, followed by explantation of the infected endograft with ligation of the descending thoracic aorta in the second. This approach controls the focus of infection while allowing flow to the aorta distal to the infected endograft, minimizing visceral ischemia time.

Current indications for the intrathoracic transposition of the omentum

Background

The intrathoracic transposition of the omentum (ITO) has been reported with more or less good results in various clinical circumstances but with no clear guidelines or indications.

Methodology and review

This article reviews the main clinical situations in which omento-plasty (OP) may be taken into consideration by the thoracic surgeons: mediastinitis and deep sternal infections after median sternotomy, reinforcement of the eso-gastric anastomosis after esophagectomy, prevention and treatment of the bronchial fistula after pulmonary resection, space-filling procedures for empyema, mediastinal tracheostomy, management of the infected intrathoracic vascular grafts / ventricular assist devices and heart OP. For each clinical situation we have performed a literature review with analysis of the most relevant published papers searching for an evidence-based approach for the use of the ITO/OP in thoracic surgery.

Conclusions

OP may be an elegant solution for a wide range of problems in thoracic surgery. In the published literature, there are mainly case-reports and relatively small series published resulting in a low level of evidence for both ITO as a surgical technique by itself, as well as for the use of OP in various clinical situations involving the chest structures. The indications for its use in thoracic surgery are based more on common sense and the lack of other solutions.

Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae

INTRODUCTION

Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas.

AREAS COVERED

This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology.

EXPERT COMMENTARY

Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.

Post-sternotomy deep wound infection following aortic surgery: wound care strategies to prevent prosthetic graft replacement†

OBJECTIVES

The aim of this study was to evaluate the early and long-term outcomes of our multidisciplinary strategy for treating deep sternal wound infection after aortic grafting, which consisted of debridement by a plastic surgeon, negative pressure wound therapy with continuous irrigation and chest wall reconstruction.

METHODS

We performed a retrospective analysis of 18 patients who had a deep sternal wound infection following aortic grafting through a median sternotomy between January 2009 and December 2017. All patients had organisms cultured from mediastinal tissue within 2 months from the initial aortic surgery. The prosthetic grafts were exposed in 15 patients during resternotomy. Our protocol involved repeat debridement and negative pressure wound therapy with continuous irrigation twice a week until the results of the culture were negative and chest wall reconstruction was complete.

RESULTS

The mean duration from primary aortic surgery to resternotomy was 23.7 ± 15.9 days. Except for 1 patient, 17 patients underwent chest wall reconstruction. The mean duration from resternotomy to chest wall reconstruction was 31.1 ± 28.0 days. The hospital mortality rate was 16.7% (3 patients), although no patients died of wound-related causes. The mean follow-up period was 2.9 ± 2.5 years. Overall survival was 69.6 ± 11.4% at 1 year and 54.2 ± 13.3% at 5 years. Freedom from reoperation for reinfection was 94.4 ± 5.4% at 5 years.

CONCLUSIONS

Our wound care strategy achieved acceptable early and late survival in patients who had deep sternal wound infection following aortic grafting. This strategy may benefit those who experience this devastating complication.

Successful surgical repair of aorto-esophageal fistula due to fish-bone ingestion

Aorto-esophageal fistula is a rare and potentially lethal disease. The main causes are ruptured aortic aneurysm, foreign body ingestion, complication of surgical or endovascular repair of thoracic aortic aneurysm, and esophageal malignancy. We report a case caused by fish-bone ingestion. He underwent replacement of proximal descending aorta using circulatory arrest and trans-hiatal esophagectomy in the same sitting. A second-stage esophago-coloplasty was performed after 6 months for establishing digestive tract continuity.