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Surg Today (2004) 34:357–359 DOI 10.1007/s00595-003-2697-x
Successful Repair of an Aortoesophageal Fistula Caused by a Thoracic Aortic Aneurysm: Report of a Case Yoshiyuki Tokuda1, Masahiko Matsumoto1, Takaaki Sugita1, Junichiro Nishizawa1, Katsuhiko Matsuyama1, Kazunori Yoshida1, Takehiko Matsuo1, and Masaaki Awane2 Departments of 1 Cardiovascular Surgery and 2 General Surgery, Tenri Hospital, 200 Mishima, Tenri, Nara 632-8552, Japan
Abstract Aortoesophageal fistula occurring as a complication of a thoracic aortic aneurysm is difficult to repair because of the contaminated surgical field. We report the case of a 67-year-old man in whom an aortoesophageal fistula developed secondary to a dissecting thoracic aortic aneurysm. We performed in situ graft repair of the aneurysm, then covered the site with omentum and resected the esophagus to prevent graft infection. About 5 months later, the esophagus was reconstructed subcutaneously using an ascending colon pedicle. The patient recovered well and has resumed leading a normal life. Key words Aortoesophageal fistula · Thoracic aortic aneurysm · Omental transfer
Introduction Aortoesophageal fistula resulting from a thoracic aortic aneurysm is a rare cause of upper gastrointestinal bleeding. It is fatal without surgical intervention, but repair of the aneurysm is complicated due to the infected surgical field. We report a case of aortoesophageal fistula occurring secondary to a dissecting thoracic aortic aneurysm, which we successfully treated by in situ graft replacement of the aorta followed by coverage with omentum and esophageal resection to prevent graft infection.
Case Report A 67-year-old man was admitted to our hospital following an episode of hematemesis. The patient had been
Reprint requests to: Y. Tokuda Received: November 11, 2002 / Accepted: July 8, 2003
diagnosed with a DeBakey IIIb dissecting thoracic aortic aneurysm 3 months earlier, was and treated medically in another hospital. Computed tomography (CT) of the chest showed a large dissecting aneurysm of the descending aorta. An emergency endoscopy demonstrated oozing from the upper thoracic esophagus, which was compressed by a pulsatile mass located 25 cm from the mouth. The esophagus was covered with thrombi, and the stomach was distended and filled with thrombi. A diagnosis of aortoesophageal fistula secondary to a dissecting thoracic aortic aneurysm was made, indicating the need for emergency surgery. Cardiopulmonary bypass was instituted between the femoral artery and the right atrium, via the femoral vein. The descending aorta and distal arch were exposed through a left lateral thoracotomy. A 7-cm aneurysm was found, extending from just distal to the left subclavian artery to 5 cm above the diaphragm, with the aorta strongly adherent to the wall of the upper thoracic esophagus (Fig. 1). Circulatory arrest was induced with deep hypothermia and the aorta was opened longitudinally. The descending thoracic aneurysm was replaced with a 28-mm woven Dacron graft from just distal to the left carotid artery to the tenth intercostal level. Distal anastomosis was performed using a double-barreled technique to preserve blood flow in both the true and false lumens. The lateral thoracotomy was then extended inferiorly to the upper abdomen. An omental pedicle, with its base at the level of the right gastroepiploic artery, was created and transferred to the thoracic cavity. The Dacron graft was covered with this omental pedicle to prevent infection. The esophagus was then divided and a tube gastrostomy was created. The patient was placed in the left decubitus position and a right thoracotomy was performed to accomplish thoracic esophagotomy, allowing the esophagus to be completely removed from the thoracic cavity. Finally, the patient was placed in the supine position and a cervical esophagostomy was done.
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Fig. 1. Computed tomography scan of the chest showed a large dissecting aneurysm of the descending aorta, compressing the esophagus. Emergency endoscopy demonstrated oozing from the thoracic esophagus, and a diagnosis of aortoesophageal fistula secondary to a dissecting thoracic aortic aneurysm was made
The patient had an uneventful recovery and was discharged with a gastric tube feeding in situ and on longterm treatment with parenteral clindamycin. About 5 months after the first operation, the esophagus was reconstructed using the ascending colon pedicle. A pedicled ascending colon conduit was transferred into the subcutaneous space anterior to the sternum and connected between the cervical esophagus and the stomach. Oral feeding was started 16 days after the subcutaneous esophageal reconstruction, and the patient is now leading a normal life.
Discussion Repair of an aortic aneurysm complicated by an aortoesophageal fistula is very difficult because of the contaminated surgical field. Moreover, as the aneurysm must be replaced with a prosthetic graft, the repair is especially prone to graft infection and septic complications. Some patients have been treated by creating an extra-anatomic bypass from the ascending aorta to the abdominal aorta, but this is a very complex approach necessitating additional surgical trauma.1,2 An alternative method of creating an extra-anatomical bypass is by using an axillary-femoral graft, but these grafts are restricted in size, and may not be able to supply sufficient distal flow.3 The successful implantation of a cryopreserved aortic allograft to treat a mycotic thoracic aneurysm has been reported;4 however, this is not currently available in Japan. Therefore, despite the po-
Y. Tokuda et al.: Successful Repair of Aortoesophageal Fistula
tential hazards of an infected field, we found in situ replacement of the thoracic aortic aneurysm to be the best surgical option. The omentum has been used very effectively in the management of an infected surgical field. For example, the transfer of omentum to the mediastinum has been successfully employed for postoperative mediastinitis.5 In the present case, the placement of a viable omental flap into a potentially infected thoracic cavity as well as around a graft proved similarly effective for limiting mediastinitis and graft infection. There is currently no consensus on whether primary repair or esophageal resection is the better treatment option for the esophageal tear associated with aortoesophageal fistula. Although some reports recommend primary repair of the esophagus, leakage from the repair site is a frequently reported complication.6 As mediastinal contamination in the presence of a prosthetic graft is likely to result in fatal sepsis, we think that complete thoracic esophageal resection followed by staged reconstruction is more appropriate. To reconstruct the esophagus, the colon should be used as a conduit, rather than the stomach, which lacks blood supply from the right gastroepiploic artery after omental transfer. Moreover, subcutaneous rather than substernal reconstruction using the colon pedicle is advisable as anastomotic failure could induce mediastinitis and graft infection if the substernal route is used. Because long-term survival depends on the prevention of late graft infection, antibiotic coverage against oral flora, including anaerobes, should be continued. We gave our patient 6 weeks of intravenous antibiotics followed by 6 months of parenteral clindamycin. This treatment approach led to a successful outcome. In conclusion, an aortoesophageal fistula caused by a thoracic aortic aneurysm is always fatal without surgical intervention. Therefore, prompt diagnosis followed by surgery is essential for survival. To prevent graft infection in the potentially infected surgical field, we recommend graft replacement of the aneurysm, with omental coverage and esophageal resection followed by staged subcutaneous esophageal reconstruction using a colon pedicle, with long-term antibiotic therapy.
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Y. Tokuda et al.: Successful Repair of Aortoesophageal Fistula 4. Vogt PR, Turina MI. Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts. Ann Thorac Surg 1999;67:1986–9. 5. Heath BJ, Bagnato VJ. Poststernotomy mediastinitis treated by omental transfer without postoperative irrigation or drainage. J Thorac Cardiovasc Surg. 1987;94:355–60.
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