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Ann Thorac Surg 2001;71:759
© 2001 The Society of Thoracic Surgeons

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Correspondence

Types of esophageal repair after primary aortoesophageal fistula resection

^a Thoracic Surgical Clinic, Semmelweis University, H-1529 Budapest, Piheno u. 1, Hungary

e-mail: kotsis{at}koranyi.hu

To the Editor

Reardon and associates [1] recently published an interesting review on primary aortoesophageal fistula, which is the most uncommon type of esophageal disruption. Inappropriate removal of an esophageal foreign body also may lead to a similar life-threatening injury.

I agree with the authors that in a locally infected field, if primary repair of the esophageal tear is attempted, buttressing the suture line always should be included in the closure procedure. Use of the aneurysm wall in the last case of the authors was an ingenious option.

If the esophageal wall defect is not suitable for suture closure, patch reconstruction with a diaphragmatic pedicled flap, according to Rao and colleagues [2] may be a useful alternative to resection [3] and considerably may reduce the risk of surgery.

Diaphragmatic flaps are the most ideal soft-tissue material to wrap middle or lower-third esophageal defects [3, 4]. These flaps avoid intra-abdominal extension of the repair and use of the omentum.

Bilateral Urschel-type exclusion and diversion with bandings [5] or absorbable suture material is another method to prevent breakdown of the esophageal closure.

In critically ill patients with large esophageal defects after aortic aneurysm removal, Johnson-type esophageal exclusion is a lower-risk alternative to esphageal resection followed by secondary substernal bypass with gastric tube or pedicled colon graft.

References

1. Reardon M.J., Brewer R.J., LeMaire S.A., Baldwin J.C., Safi H.J. Surgical management of primary aortoesophageal fistula secondary to thoracic aneurysm. Ann Thorac Surg 2000;69:967-970.[Abstract/Free Full Text]
2. Rao K.S.V., Mir M., Cogbill C.I. Management of perforations of the thoracic esophagus. Am J Surg 1974;127:609-612.[Medline]
3. Kotsis L., Agócs L. The effectiveness of diaphragmatic pedicled grafts in esophageal injuries and wall reconstruction. Eur J Cardiothorac Surg 1998;14:218-219.
4. Mineo T.C., Ambrogi V. The diaphragmatic flap: a multiuse material in thoracic surgery. J Thorac Cardovasc Surg 1999;118:1084-1089.[Abstract/Free Full Text]
5. Kotsis L., Kostic S., Zubovits K. Multimodality treatment of esophageal disruptions. Chest 1997;112:1304-1309.[Abstract/Free Full Text]

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