Aortoesophageal fistulae due to gunshot wounds: report of two cases with one survivor

Traumatic Arterio-Enteric Fistula-A Report of 2 Cases With Review of Literature

BACKGROUND

Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries.

CASE DESCRIPTION

Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully.

CONCLUSION

Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.

Aortic squamous metaplasia in a patient with aortoesophageal fistula secondary to thoracic aortic aneurysm: an autopsy case

Aortoesophageal fistula (AEF) is highly lethal. A 74-year-old man presented with hematemesis and consciousness loss. He had a long-term history of hypertension and gout. Computed tomography revealed an aneurysm of the distal descending thoracic aorta, which was treated by insertion of an aortic stent graft. After 24 days of stenting, endoscopic examination revealed an AEF. After 6 months of stenting, he died owing to mediastinitis. On autopsy, macroscopically, we found a 4 × 2.5-cm, oval, well-circumscribed AEF. We identified squamous epithelium in the area surrounding the AEF that covered the thoracic aorta inner cavity. Immunohistochemical analysis revealed that the squamous epithelium in the thoracic aorta was positive for p63 and 34βE12. In conclusion, we encountered a long-term AEF case with aortic squamous metaplasia. To the best of our knowledge, human aortic metaplasia has never been reported. In the present case, aortic squamous metaplasia retained continuity with the esophageal squamous epithelium; therefore, the migration of the squamous epithelium through the AEF may have been induced by aortic erosion.

Aortoesophageal fistula: value of in situ aortic allograft replacement

PURPOSE

The purpose of this report is to describe our experience in management of aortoesophageal fistulas (AEF) with special emphasis on the value of in situ aortic allograft replacement.

PATIENTS

Nine patients presenting with AEF were observed between May 1988 and April 2002. There were 4 men and 5 women with a mean age of 54.3 years (range, 32-77 years). Six patients presented secondary AEF after aortic repair. Two patients presented primary AEF after rupture of an atherosclerotic aneurysm into the esophagus. In the remaining patient, AEF was caused by swallowing a fishbone. In 6 cases involving true AEF with a direct communication between the aorta and esophagus, massive exsanguinating hematemesis occurred. It was usually preceded by minor sentinel bleeding. Two patients presented esophagoparaprosthetic fistula (EPPF). One patient presented primary AEF that was contained by a large thrombus in the communication. The clinical picture in these 3 patients involved severe sepsis without hemorrhage.

RESULTS

Two patients died as a result of massive hemorrhage before assessment and surgical treatment could be undertaken. One 77-year-old woman presenting EPPF refused to undergo surgery and died because of infection. The remaining 6 patients underwent surgical treatment with various outcomes. One man died during thoracotomy caused by exsanguinating hemorrhage. One woman presenting EPPF was treated by exclusion followed by ascending aorta to abdominal aorta bypass grafting, removal of the prosthesis, esophageal exclusion, and directed esophageal fistula. She died of infection. The other 4 patients were treated by in situ aortic allograft replacement. The damaged esophagus was repaired by using the Thal technique in 1 patient. In the remaining 3 cases subtotal esophagectomy was performed in association with cervical esophagostomy, ligation of the abdominal esophagus, gastrostomy, and jejunostomy. One patient died of sepsis during the first 24 hours after the operation. The other 3 patients underwent secondary esophagoplasty and survived with no further sign of infection. Mean duration of follow-up in the survivor group was 53 months (range, 15-95 months). Overall 6 patients, including 3 that did not undergo surgical treatment, died and 3 patients survived.

CONCLUSION

Our experience confirms that AEF is a rare but catastrophic disorder. In situ allograft replacement usually in association with subtotal esophagectomy appears to be an excellent salvage modality whenever emergency surgery is feasible.

Mediastinal trauma

The evaluation of mediastinal trauma has undergone some important changes in the last few years. Electrocardiography (ECG) combined with troponin measurements have become the standard of evaluation of suspected blunt cardiac trauma. Spiral computerized tomography (CT) scan has largely replaced angiography for suspected blunt aortic rupture. There is good evidence that with a suspicious mechanism of injury the thoracic aorta should be evaluated irrespective of chest X-ray findings.

In penetrating trauma the introduction of trauma ultrasound in the emergency room has revolutionized the early diagnosis of cardiac tamponade. Most mediastinal gunshot wounds in haemodynamically stable patients can safely be managed non-operatively. Evaluation of the direction of the bullet tract by means of spiral CT scan has replaced angiography and oesophageal studies in about 75% of patients with mediastinal gunshot wounds who are haemodynamically stable.

Aortoesophageal fistula: recognition and diagnosis in the emergency department

An aortoesophageal fistula is a life-threatening cause of gastrointestinal bleeding where an abnormal communication between the esophagus and the aorta may result from a thoracic aortic aneurysm, foreign body ingestion, esophageal malignancy, or postoperative complications. The diagnosis can be made on the basis of clinical findings alone. Classic patients present with the triad of midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval (Chiari's triad). The identification of massive upper gastrointestinal hemorrhage that is bright red and arterial in nature is characteristic. Most diagnostic tests have significant individual limitations. Endoscopy of the upper gastrointestinal tract should exclude alternative bleeding sources and may show a submucosal hematoma. Aortography may be useful during active hemorrhage to demonstrate the fistula, but results of aortography may be negative during the symptom-free interval. Dynamic computed tomography may be a more rapid alternative. For patients who are in stable condition after the sentinel hemorrhage, a confirmatory test is reasonable. Patients in unstable condition should undergo immediate surgery. Survival is now possible with rapid surgical intervention.

Aortic balloon control of a traumatic aortoenteric fistula after damage control laparotomy: a case report

Aortoenteric fistula is a rare complication of abdominal trauma. We present a case of a patient with multiple gunshot wounds to the abdomen and thorax in whom control of injury required staged operations. An aortoenteric fistula developed, presenting a diagnostic and therapeutic challenge. The operative control of aortic bleeding was by a retroperitoneal approach to the aorta and facilitated by the use of percutaneous aortic balloon catheters. The patient survived to leave hospital. This case highlights a rare trauma complication, the use of "damage control" for the severely injured abdomen and the technique of intra-arterial balloon control of bleeding from inaccessible locations.

Acute suprarenal aortogastric fistulae caused by gunshot wounds: the importance of early recognition in directing surgical strategy

Penetrating suprarenal aortic injuries carry high mortality rates. Difficulties in surgical exposure and bleeding control in this area add to the ominous prognosis. In rare occasions, synchronous injury to the adjacent upper part of stomach may lead to an acute aortogastric fistula, resulting in aortic bleeding into the stomach instead of the peritoneal cavity. Filling of the stomach with blood may temporarily tamponade the aortic perforation. Distortion of this delicate communication during dissection before proximal and distal vascular control is achieved could result in catastrophic hemorrhage. Therefore, recognition of the importance of a fully distended stomach at the suspicion of aortic injury is essential in directing a particular surgical strategy that aims to achieve an unrestricted operative exposure and successful bleeding control.