An aorto-oesophageal fistula treated with total arch repair combined with oesophageal repair

Abstract

Aorto-oesophageal fistula is a rare but fatal disease. Open surgical repair or endotube repair of aorta and oesophagus save patients from circulatory deterioration, major haematemesis and severe infection. Here we present a rare case of an aorto-oesophageal fistula in the right hemi-arch caused by a fish bone treated with an alternative surgical strategy. Total aortic arch repair using the frozen elephant trunk procedure combined with oesophageal repair were performed. No aortic fistula, oesophageal fistula or artificial graft infection occurred in the follow-up.

INTRODUCTION

Aorto-oesophageal fistula (AEF) is a rare but devastating condition caused by ruptured aortic aneurysm, foreign body ingestion, advanced oesophageal malignancy, caustic injury or postoperative aortic disease [1]. Once AEF occurs, it could lead to fatal haemorrhage and infection. Here we report a case of an AEF between the right hemi-arch and oesophagus secondary to oesophageal foreign body treated with total arch repair combined with oesophageal repair.

CASE REPORT

A 66-year-old man was admitted to hospital complaining of chest and back pain lasting for 1 month. One month ago, the patient accidentally swallowed a fish bone, and then felt pain in chest and back. The chest computed tomography scan showed an ascending aortic aneurysm, and he was treated conservatively. However, chest and back pain recurred and worsened and followed by haematemesis twice in the next month. Then he was transferred to our hospital, and the contrast-enhanced aortic computed tomography scan showed the presence of oesophageal foreign body, which had caused AEF, oesophageal perforation and aortic arch pseudoaneurysm (Fig. 1A and B). He had a low-to-mild degree fever, with increased inflammatory markers (C-reactive protein 173.9 mg/l, procalcitonin 1.24 ng/ml). Emergency surgery was arranged immediately. During the operation, swelling was found from the posterior wall of the ascending aorta to the posterior wall of the aortic arch. After incision, multiple pus and blood clots were observed and a 3-cm long fish bone was protruding from the infected tissue (Fig. 1C). A 0.7 × 3cm fistula was spotted between the oesophagus and the aorta (Fig. 1D). After the complete removal of the abscess and necrotic tissue, the fistula and the outer oesophageal membrane were sutured. Between the oesophageal fistula and the right thoracic cavity, the pericardium and the mediastinal pleura were opened. And then the mediastinal pleura tissue was mobilized to cover the oesophageal fistula. Ascending aortic replacement, total arch repair and frozen elephant trunk (Cronus^®, MicroPort Medical, Shanghai, China) were performed simultaneously. Iodophor gauze was placed between the artificial graft and oesophagus and sternal closure was delayed. Pus culture showed streptococcus pharyngitis and streptococcus constellation infection, vancomycin and imipenem were administered for 3 weeks according to the drug sensitivity results. A gastric tube was placed for gastrointestinal decompression and a nasoenteric feeding tube was placed to provide nutritional support. Two days later, we performed debridement again and closed the chest. The postoperative recovery was uneventful. The patient began to eat in 20 days after operation. Aortic fistula, oesophageal fistula or artificial graft infection was not found in postoperative examination (Fig. 2). The patient was discharged 30 days after operation and still in a good condition during the 10-month follow-up.

Figure 1:

Pseudoaneurysm of the thoracic aorta, 64 mm in diameter, was formed (A). The fish bone (arrow) was found in the mediastinum on computed tomography (B). The fish bone about 3-cm long was successfully removed (C). Aorto-oesophageal fistula was explored during the operation (D).

Figure 2:

Postoperative computed tomography angiography (A) and esophagography (B) showed no leakage.

COMMENT

Fish bone is one of the most common oesophageal foreign bodies causing AEF [2]. Traditional surgery includes cardiovascular surgery for graft replacement, oesophageal resection, cervical oesophagostomy, oesophageal staged reconstruction and omental wrapping of the graft [3, 4]. Because of the severity of the disease, the complexity of the operation, together with postoperative infection and bleeding, the outcome of traditional surgery was poor [2]. Thoracic endovascular aortic repair has been developed recently as a minimally invasive therapy for AEF [5]. Due to the possibility of graft infection and stent leakage, thoracic endovascular aortic repair was greatly limited in its application.

In this case, the difficulties in the operation were controlling the postoperative infection and choosing the appropriate treatment strategy for AEF. The patient was discharged uneventful after operation. We think the success of this case is attributed to the following strategies:

1. The infected tissue was removed and the mediastinal tissue was cleaned repeatedly.

2. The mediastinal pleura tissue was mobilized to cover the oesophageal fistula to prevent infection of the graft and stent.

3. Adequate drainage was performed during the operation.

4. The gastric tube for gastrointestinal decompression was used to reduce the infection of the mediastinum from the digestive tract.

5. Appropriate and sufficient antibiotic therapy according to drug sensitivity results from pus culture facilitated infection control.

This suggests that AEF can be treated with total arch repair using the frozen elephant trunk combined with oesophageal repair, which could reduce the trauma, making it a safer strategy leading to fast recovery.

Conflict of interest: none declared.

Reviewer information

Interactive CardioVascular and Thoracic Surgery thanks Matthieu Thumerel and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.