Ann Thorac Surg 1998;66:936-938
© 1998 The Society of Thoracic Surgeons
Case Reports
Successful repair of aortoesophageal fistula secondary to traumatic pseudoaneurysm
Talat S. Chughtai, MDa,
Nathan M. Sheiner, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, McGill University, Montreal, Canada
Accepted for publication March 23, 1998.
Address reprint requests to Dr Sheiner, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Canada H3T 1E2
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Abstract
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There have previously been only rare reported survivors of an aortoesophageal fistula resulting from a traumatic pseudoaneurysm. We report a case of a young man with a dramatic presentation who was successfully managed by immediate operative repair. A prosthetic graft was sewn within the sac of the aneurysm, with the aneurysm wall being used to protect the graft, and the esophagus was resected. Staged reconstruction of the esophagus was subsequently performed successfully. The patient is now alive and well 2
years later.
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Introduction
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Aortoesophageal fistula (AEF) from all causes is a rare and usually fatal source of upper gastrointestinal hemorrhage [1]. Those specifically resulting from a traumatic false aneurysm constitute a very small percentage of all AEFs [2]. Rare survivors [3] of a traumatic AEF have been reported in the modern literature. We report the successful management of a patient with an AEF secondary to a traumatic aortic pseudoaneurysm.
A 23-year-old man with a previous history of blunt chest trauma presented with massive hematemesis. Four months earlier, the patient was involved in a motorcycle accident in Portugal, where he was hospitalized and treated for multiple rib fractures. After discharge from the hospital, he returned to Canada, where 1 month after the initial injury, he presented to the pulmonary clinic with shortness of breath and chest pain. A chest radiograph at that time revealed a pleural effusion, which was treated with chest tube drainage for a period of 3 days. He improved and was discharged from the hospital. Two months later, fever and substernal chest pain developed. An electrocardiogram revealed evidence of pericarditis, and an echocardiogram demonstrated a moderate pericardial effusion. The effusion resolved with steroid treatment and the patient was again discharged. While attending the pulmonary clinic 1 week later, he began to feel dizzy and nauseated, and suddenly vomited a large amount of bright red blood. The patient was immediately taken to the emergency room, where he was found to have a blood pressure of 80/50 mm Hg. Aggressive resuscitative measures were started, a nasogastric tube was placed, and a massive amount of bright red blood (about 2 L) was aspirated from his stomach. In spite of the gastric tube, he continued to vomit large amounts of bright red blood. The hemoglobin level at this time was 120 g/L.
The patient was immediately taken by the general surgical staff to the operating room, where a laparotomy and long gastrotomy revealed that the bleeding was coming from the esophagus and not from the stomach. A recent chest radiograph on hand was then re-reviewed and it demonstrated some haziness in the area of the aortic knob. A clinical diagnosis of posttraumatic aortoesophageal fistula was made. The gastrotomy and abdominal incision were rapidly closed, the patient was placed in the right lateral decubitus position, and a high left posterolateral thoracotomy was performed. The area of the aortic knob was found to be edematous and indurated, and a 4-cm false aneurysm was found along the medial aspect of the aorta, just distal to the origin of the left subclavian artery. After a segment of pericardium (thickened from the recent pericarditis) was excised, a heparinized Gott shunt was inserted into the apex of the left ventricle. The distal end of the shunt was placed into the descending thoracic aorta. The aorta was cross-clamped just above the left subclavian artery and the latter was double looped. The descending thoracic aorta was cross-clamped about 10 cm distal to the left subclavian artery, and flow was commenced through the Gott shunt. After the aneurysmal segment of aorta was opened, a large fistula was apparent between the false aneurysm and the adjacent esophagus. The opening in the esophagus was approximately 2 cm in diameter and partially filled with thrombus. After copious irrigation of the area with antibiotic solution, an 18-mm Hemashield (Meadox Medicals, Oakland, NJ) graft was sewn within the sac of the false aneurysm and the residual wall of the aneurysm was sutured around the graft. Because the fistulous opening in the esophagus was large and could not be safely closed primarily, the thoracic esophagus was resected and the proximal and distal ends were stapled. At this point, the patient had received 10 L of crystalloid and 32 units of blood and blood products, and a severe coagulopathy had developed. The operation was terminated at this point, the chest was rapidly closed, and the patient was taken to the intensive care unit in stable condition on inotropic support. Forty-eight hours later, the patient was returned to the operating room for placement of a feeding jejunostomy and a decompressing gastrostomy, as well as for construction of a cervical esophagostomy.
Six weeks later, after a stable postoperative course, the patient underwent reconstruction of his esophagus with a left colon interposition graft placed in the substernal position. Unfortunately this was complicated by necrosis of the graft 12 days later as a consequence of venous infarction. This necessitated removal of the infarcted colon and drainage of the anterior mediastinum. Three months later, a second graft, consisting of the right colon and a segment of terminal ileum, was placed substernally to again reconstruct the esophagus. The patient now remains well, 2 years after his initial presentation, and is getting married this month.
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Comment
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In a review of the literature done by Hollander and Quick [2] of all 500 known cases of AEF, only 3 (0.6%) occurred as a result of a traumatic false aneurysm after closed chest injury. Most patients with AEF present with chest pain and a sentinel hemorrhage, followed by a variable asymptomatic period, and finally by rapid and often fatal exsanguination [1, 2, 4]. The case we describe herein did not present with a history of prodromal hemorrhage. The 3 patients described by Hollander and Quick [2], all of whom died, and the surviving patient reported by Wang and associates [3], presented late (at 8, 19, 21, and 11 years, respectively) after their injury. Our patient presented only 4 months after the history of chest trauma. Because of the exsanguinating hemorrhage in our patient, there was no time for any diagnostic procedures. We relied on the clinical features of the case, the patient’s history, and a simple chest radiograph to make the diagnosis and proceed to a definitive operation.
In addition to general medical optimization, the patient presenting with an AEF requires immediate surgical intervention. A high left thoracotomy incision provides the best exposure to both the aorta and the esophagus [1], because the traumatic aneurysm is usually situated just distal to the left subclavian artery. The thoracic aorta should be rapidly controlled with proximal and distal clamping only [5] or, as in our case, bypass with a Gott shunt to allow for a more unhurried approach [4]. The point of fistulous communication can usually be identified from within the aneurysm itself after it has been opened [4, 5]. The aneurysm is then best repaired by an in-situ prosthetic graft replacement [1, 3, 4]. Snyder and Crawford [5] recommend removal of the entire circumference of the aneurysmal wall. In the case presented, we wrapped the aneurysmal wall around the graft, protecting it from the surrounding tissues. We did not feel the need to further protect the graft by using a parietal pleural flap as has been reported by others [1, 3, 4].
It is essential to take care of the esophageal pathology at the time of pseudoaneurysm repair; otherwise one risks inevitable sepsis from an esophageal leak [3]. Much controversy exists as to how one should approach the esophageal lesion initially. Many advocate performing only a debridement of the devitalized tissue followed by primary repair, unless local conditions preclude this approach [1, 3, 4]. However, using this approach initially, Snyder and Crawford [5] suffered the consequences of leakage and mediastinal sepsis, necessitating a subsequent esophagectomy. In a second case reported by Snyder and Crawford, they proceeded directly with esophagectomy, concluding that this was more reliable than primary closure. Bogey and colleagues [4] used the endarterectomized medial and lateral adventitial wall of the aortic aneurysm to patch the esophageal repair. We performed an esophagectomy in our patient because of the substantive size of the fistulous opening (Fig 1), the presumed contamination of the operative field, and the already compromised condition of the patient. All these factors would have made primary closure difficult and risky. No attempt was made to perform an esophageal reconstruction at the time of the initial operation because of the severe coagulopathy and unstable condition of the patient. To reconstruct the esophagus, it was necessary to use the colon as a conduit rather than the stomach because of the long gastrotomy and gastrostomy that had been performed. Necrosis developed in the first colonic graft likely because of venous obstruction. Nevertheless, a second colonic graft is functioning well, and our patient is currently one of the few reported survivors of a posttraumatic AEF.
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Fig 1. Gross pathologic specimen of resected esophagus (adventitial aspect) demonstrating large fistulous opening (arrow).
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References
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- Fernando HC, Benfield JR. Surgical management and treatment of esophageal fistula. In: Meguid MM, Campos AC, eds. Surgical management of gastrointestinal fistulas—the surgical clinics of North America. Philadelphia: Saunders, 1996;76(5):1131–2.
- Hollander J.E., Quick G. Aortoesophageal fistula: a comprehensive review of the literature. Am J Med 1991;91:279-287.[Medline]
- Wang N., Sparks S.R., Bailey L.L. Staged repair using omentum for posttraumatic aortoesophageal fistula. Ann Thorac Surg 1994;58:557-559.[Abstract/Free Full Text]
- Bogey W.M., Thomas J.H., Hermreck A.S. Aortoesophageal fistula: report of a successfully managed case and review of the literature. J Vasc Surg 1992;16:90-95.[Medline]
- Snyder D.M., Crawford E.S. Successful treatment of primary aorta–esophageal fistula resulting from aortic aneurysm. J Thorac Cardiovasc Surg 1983;85:457-463.[Abstract]
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Abstract
Introduction
