Management options for aorto-oesophageal fistula: case histories and review of the literature

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.

A novel approach to surviving an acute aorto-oesophageal fistula: A case report

INTRODUCTION AND IMPORTANCE

Acute aorto-oesophageal fistula poses a significant mortality risk, requiring immediate and decisive medical intervention. This report highlights the critical need for innovation in emergency surgical responses.

CASE PRESENTATION

A 57-year-old male, with a history of aortic repair, presented with chronic anaemia and dysphagia. He suffered a cardiac arrest from massive hematemesis during surgery for an infected thoracic hematoma. Lacking a Stengsten-Blackmore tube, a 26Fr Foley catheter was used to control the bleeding. This measure stabilized the patient enough for a definitive endovascular repair with aortic stents, which successfully managed the bleeding.

CLINICAL DISCUSSION

The treatment objectives for this condition include initial control of oesophageal bleeding, followed by endovascular management to further control the bleeding, subsequently releasing the oesophageal control, and ultimately preventing infection through the administration of intravenous antibiotics.

CONCLUSION

This case illustrates the importance of adaptability and the use of unconventional methods in emergency situations, demonstrating that innovative solutions can be lifesaving in critical surgical emergencies.

A fatal aorto-oesophageal fistula due to a mutton bone: A case report

INTRODUCTION AND IMPORTANCE OF THE CASE

Aorto-oesophageal fistula (AEF) following foreign body ingestion is rare and conservative management is always fatal. The delayed presentation further confounds poor outcomes.

PRESENTATION OF CASE

A 46-year-old South-Asian woman presented with pain and difficulty in swallowing following ingestion of a mutton-containing meal. The patient refused urgent upper GI endoscopy and was initially managed conservatively on the basis of the resolution of symptoms and hemodynamic stability and was discharged home. On review a week later, the patient did not consent to a UGIE. She presented the next day with a severe upper GI bleed. Due to profuse haemorrhage, a bleeding point could not be identified, and she suffered a cardiac arrest. Attempts at resuscitation were unsuccessful. The autopsy revealed an AEF caused by a sharp mutton bone lodged in the lower oesophagus.

CLINICAL DISCUSSION

High-risk food bolus impactions such as the ones caused by sharp objects need urgent endoscopy to confirm the position and extraction if safe. AEF occurs with time and could result in massive haemorrhage and mediastinitis. Endoscopic stenting, thoracoscopic surgery, and open repair are methods of emergent and definite management that still carry significant mortality.

CONCLUSION

Management of AEF requires early diagnosis with a high index of suspicion, endoscopic and CT-based angiography studies, and surgical interventions tailored to patients based on the available expertise. High-risk patients should be similarly educated on the probable complications and the symptomatology.

Salvaged, Staged, and Safer Management of Aortoesophageal Fistula and Mediastinitis After Removing a Pork Bone: A Case Report

Aortoesophageal fistula (AEF) caused by esophageal foreign body (EFB) ingestion is a life-threatening condition with a very low survival rate. However, the optimal management strategy remains undetermined. Here, we describe our successful management of a patient with AEF and mediastinitis. A 36-year-old man developed persistent chest and back pain and vomited fresh blood three days after removal of a pork bone in the esophagus under endoscopy in a local hospital. Computed tomography (CT) confirmed bilateral pulmonary infections, mediastinitis, and fistula of the aortic arch. After a multidiscipline discussion, a comprehensive staged strategy was made including salvaged thoracic endovascular aortic repair (TEVAR) to control fatal bleeding, adequate mediastinal debridement, drainage with cervical incision, and video-assisted thoracoscopic surgery, as well as jejunostomy to prevent nasal or gastrostomy reflux from aggravating the mediastinal infection. Furthermore, systematic personalized nutrition support and antibiotics were provided. The patient recovered well and has survived for 50 months until now. Careful assessment should be made with CT to ascertain the risk of AEF before and after the removal of EFB. A salvaged staged strategy of TEVAR with adequate mediastinal debridement and drainage in a less invasive approach may be a safer alternative for AEF patients with infections caused by EFB.

Combined minimally invasive treatment for delayed aortoesophageal fistula caused by fishbone

Aortoesophageal fistula caused by esophageal foreign body is a rare, catastrophic condition. We report a case of delayed aortoesophageal fistula caused by fishbone and associated with severe hematemesis, mediastinal abscess, and esophageal tear. We performed thoracic endovascular aortic repair (TEVAR) to control the bleeding and video-assisted thoracoscopic surgery (VATS) to drain the mediastinal abscess and repair the esophageal tear. The patient recovered with limited physical and physiological impairment after systematic treatment. This case highlights the feasibility of combined TEVAR and VATS as an optimum management strategy in cases of aortoesophageal fistula associated with severe bleeding and mediastinal abscess.

Presentation, management and outcome of aorto-esophageal fistula in young patients: two case-reports and literature review

Aorto-esophageal fistula (AEF) is a rare serious surgical event. The first case developed hematemesis 2 weeks post-sleeve gastrectomy. A covered esophageal stent was placed endoscopically. The esophageal stent implantation was followed by massive bleeding due to an AEF. A thoracic endovascular aortic repair (TEVAR) was performed. Aggravated by infection of the aortic stent, another massive bleed occurred after 1 year. The final procedure was resection of the descending aorta with reconstruction using a bovine pericardial patch. The second case presented with hematemesis post-motor vehicle accident. AEF was confirmed by aortogram and treated by TEVAR followed by fully covered esophageal stent. The patient declined definite surgery. In conclusion, initial endovascular approach is useful as a bridge procedure. Once the patient hemodynamics are stabilized, a definitive surgical repair is required. The post-repair infection and life-long antibiotics could be overcome by using bovine pericardial grafts.

Dual-modality emergency management of a rare cause of an aorto-oesophageal fistula: a case report

Aorto-oesophageal fistula (AOF) is a life-threatening condition that usually presents with upper gastro-intestinal haemorrhage. This case report details the emergency presentation and management of a 51-year-old male who presented with hematemesis secondary to an impacted denture (ingested two years previously) in the oesophagus that had led to an AOF. This necessitated urgent thoracic endovascular aortic repair followed by thoracotomy, oesophagotomy, T-tube insertion and oesophagostomy. This is the first documentation in the literature of the dual-modality management for this rare cause of AOF and demonstrates the multidisciplinary approach to successful management of this complex yet rare presentation.

Lethal aorto-oesophageal fistula 16 years after aortic prosthetic reconstruction: Delayed rupture as cause of death

The development of aorto-oesophageal fistula (AOF) is a rare complication following thoracic aortic repair. Mortality is high, in most cases due to fatal haematemesis. The clinical onset is variable, occurring approximately one year after surgery. We report a case of a lethal AOF in a 58-year-old man. He underwent open vascular surgery 16 years prior to his death due to a rupture of the descending thoracic aorta. In the early 2000s, the open vascular approach was replaced by thoracic endovascular aortic repair. As a result of this approach, the number of surgical complications has reduced, with the exception of AOF.

Aortic penetration due to a fish bone: a case report

Background

Aortoesophageal fistula (AEF) caused by an esophageal foreign body is a life-threatening crisis, with rapid progress and high mortality. The first case of AEF was reported in 1818, but the first successfully managed case was not until 1980. Although there have been some reports on this condition, in most cases, the aorta was invaded and corroded due to its adjacent relationship with the esophagus and subsequent mediastinitis. To date, few reports have described an aortic wall directly penetrated by a sharp foreign body, likely because this type of injury is extremely rare and most patients cannot receive timely treatment. Here, we present a rare case of a fish bone that directly pierced the aorta via the esophagus.

Case presentation

A 31-year-old female experienced poststernum swallowing pain after eating a meal of fish. Gastroscope showed a fishbone-like foreign body had penetrated the esophagus wall. Computed tomography revealed that the foreign body had directly pierced the aorta to form an AEF. Surgery was successfully performed to repair the aorta and esophagus. The postoperation and follow-up was uneventful.

Conclusions

For the treatment of foreign bodies in the esophagus, we should be alert of the possibility of AEFs. The effective management of AEFs requires early diagnosis and intervention, as well as long-term treatment and follow-up, which still has a long way to go.

Undiagnosed aortoesophageal fistula causing intramural hematoma of the esophagus

Aortoesophageal fistula (AEF) is a rare, but life-threatening cause of intramural hematoma of the esophagus (IHE). Typical clinical presentation of AEF includes midthoracic pain and sentinel hemorrhage followed by massive, often fatal, hematemesis, with the period between sentinel hemorrhage and massive hematemesis generally varying from hours to days. This is a case of a 61-year-old male who presented with chest pain after development of an aortoesophageal fistula and associated intramural hematoma of the esophagus. The fistula and associated hematoma were initially mischaracterized on imaging, and went undiagnosed for approximately 2 weeks before being iatrogenically disrupted during endoscopy. Though this case was successfully treated, aortoesophageal fistulas are associated with a high mortality, and aortoesophageal fistula/intramural hematoma of the esophagus should always be considered in the differential of an esophageal mass.

Repair of aortoesophageal fistula with homograft aortic replacement and primary esophageal closure

OBJECTIVES

The presence of a fistula between the thoracic aorta and the esophagus is a rare and highly fatal condition. This study aimed to evaluate the outcomes of the surgical treatment of an aortoesophageal fistula (AEF).

METHODS

We retrospectively reviewed patients with AEF who underwent surgery at our institution.

RESULTS

Between 2007 and 2018, a total of 10 patients who underwent surgery for AEF. The mean age was 63 ± 12 years, and 6 patients were men. Four patients had primary AEFs and 6 patients had secondary AEFs (3 graft replacements and 3 thoracic endovascular aortic repairs). The timing of AEF since graft replacement or thoracic endovascular aortic repairs was 21.6 ± 27 days. We performed aortic replacement with a prosthetic graft (4 patients) or a homograft (5 patients) and extra-anatomical bypass due to a previous aortic graft infection (1 patient). As a treatment of the esophagus, we conducted primary repair in 7 of 10 patients. The median lengths of hospital and intensive care unit stay were 59 days (range, 9-225 days) and 6.3 days (range, 1-87 days), respectively. Seven patients achieved oral feeding after a median 10.3 postoperative days (range, 7-78 postoperative days). Two of the 10 patients died of sepsis at 9 and 74 days postoperatively.

CONCLUSIONS

The strategy for patients with AEF should be individualized. Our surgical strategy for AEF, which includes simultaneous aortic graft replacement and primary repair of esophagus in the same operative field, is feasible and promising.

Aortoesophageal fistula and arch pseudoaneurysm after removing of a swallowed chicken bone: a case report of one-stage hybrid treatment

BACKGROUND

Aortoesophageal fistula (AEF) and arch pseudoaneurysm are rare complications induced by a foreign body, and considerable controversy remains regarding the appropriate management strategies. We herein report a successful one-stage hybrid treatment in a patient with AEF and arch pseudoaneurysm.

CASE PRESENTATION

The patient, a 40-year-old man, presented to the emergency room because of intense retrosternal discomfort for 3 days and hematemesis for 3 h. The esophagoscopy and thoracic enhanced computed tomography (CT) showed two irregular mural ulcers in the esophagus and a large saccular pseudoaneurysm at the aortic isthmus, respectively. The laboratory examinations confirmed no widespread inflammation and infection. We have successfully performed a successful one-stage hybrid treatment for this patient. Six-month follow-up shows the patient is in good condition and the esophagoscopy reveals the two mural ulcers had completely healed.

CONCLUSION

The treatment decision-making process should depend upon the patients' specific situations. Our case suggest the one-stage hybrid treatment could be an valuable alternative in some selected patients.

Sengstaken-Blakemore Tube: an extra mile

Upper gastrointestinal bleeding (UGIB) in children has multiple etiologies but fortunately is not encountered commonly by pediatricians. Aorto-esophageal fistula (AEF) in children is a rare cause of UGIB and it is mainly secondary to accidental ingestion of foreign bodies, particularly disc batteries, or after cardiothoracic surgery. In this study, we report a case of a 3-year-old child who developed de novo AEF with no prior injury to the esophagus. The child presented with massive UGIB leading to hypovolemic shock, acute kidney injury, and cardiac arrest. The torrential bleed was controlled using a Sengstaken–Blakemore Tube (SBT), which allowed urgent chest CT angiography as well as subsequent thoracotomy and repair of the fistula Unfortunately, the child succumbed to repeated cardiac arrests secondary to the renal injury and severe acidosis. This case highlights the need for the early recognition of massive UGIB in children and the requirement to make appropriately sized SBTs available in all pediatric gastroenterology units.

Aorto-esophageal fistula: the multi-disciplinary team approach to management

Aorto‐esophageal fistula is often a terminal event in many patients. The commonest causes are thoracic aortic aneurysm and esophageal malignancy. To achieve a good outcome in this condition, a MDT approach is required that combines the expertize of vascular surgeons, radiologists, and emergency physicians.

Primary aorto-esophageal fistula: Great masquerader of esophageal variceal bleeding

Aorto-esophageal fistula is a rare cause of upper gastrointestinal bleeding. Thoracic aneurysm, the most common cause of this condition, will slowly increase over time and can erode the wall of the aorta creating a fistula and leading to torrential bleeding. High clinical suspicion is required for timely diagnosis as common investigations routinely done for gastrointestinal (GI) bleeding, including esophagogastroduodenoscopy, fails to detect most cases. The classical triad of midthoracic pain, herald bleeding and fatal hematemesis described in this condition is seen in only one-third of cases. Physician should be wary of this condition, especially in elderly patients with uncontrolled GI bleeding and who are also at risk of thoracic aneurysm. Computed tomography angiogram detects most cases and emergent endovascular repair with stents controls the initial bleeding. Later, both the aorta and the esophagus are repaired and reconstructed in staged procedures.

Fatal aortoesophageal fistula bleeding after stenting for a leak post sleeve gastrectomy

Bariatric surgeries have been used in an effort to curtail the obesity epidemic. The type of surgery used has changed over time, with sleeve gastrectomies being one of the preferred options. This has been associated with some complications, including staple line leaks. We report a 43-year old female who had undergone a laparoscopic sleeve gastrectomy that was complicated by a proximal gastric pouch leak at the gastroesophageal junction. We used self-expandable stents (SEMS) in the management of the leak. Seven weeks after the insertion of the initial SEMS, the patient presented with a massive gastrointestinal bleed that could not be localized due to profuse bleeding. The patient underwent a computerized tomography angiogram and then an angiogram that could not localize the site of the bleed. An emergency laparotomy was performed and identified the source of bleeding to be an aortoesophageal fistula. A graft of the diseased area was attempted but the patient unfortunately did not survive the procedure. An aortoesophageal fistula after an esophageal SEMS insertion for a benign disease has rarely been reported and only in cases where there was a thoracic neoplasm, thoracic aortic aneurism, endovascular stent repair, foreign body or esophageal surgery. To our knowledge, this is the first case that reports an aortoesophageal fistula as a result of a SEMS for the management of a gastric pouch leak after a laparoscopic sleeve gastrectomy.