Ann Thorac Surg 2002;73:637-639
© 2002 The Society of Thoracic Surgeons
Case report
Successful repair of an aortoesophageal fistula with aneurysm from esophageal diverticulum
Fuyuhiko Yasuda, MDa,
Takatsugu Shimono, MD*a,
Hitoshi Tonouchi, MDb,
Hideto Shimpo, MDa,
Isao Yada, MDa
a Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, Mie, Japan
b The Second Department of Surgery, Mie University School of Medicine, Mie, Japan
Accepted for publication March 27, 2001.
* Address reprint requests to Dr Shimono, Division of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514, Japan
e-mail: simono-t{at}clin.medic.mie-u.ac.jp
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Abstract
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Aortoesophageal fistula is a rare, frequently fatal, cause of upper gastrointestinal bleeding, and there are few reported survivors of it. We report a successful surgical case of aortoesophageal fistula associated with an infective thoracic aortic aneurysm. The patient had been diagnosed as having an esophageal diverticulum 8 months before admission. The aortoesophageal fistula was completely resected, followed by esophagojejunum anastomosis and patch closure for the entry of the aneurysm and omental coverage to the wall of the descending aorta in one stage. In this case, esophageal diverticulum was diagnosed before the development of an aortoesophageal fistula associated with an aneurysm.
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Introduction
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Aortoesophageal fistula (AEF) is usually a fatal source of upper gastrointestinal hemorrhage. Before 1983, no one had survived surgery for an aortoesophageal fistula associated with an aneurysm. Eighty-seven percent of AEFs were the result of either a thoracic aortic aneurysm, foreign body ingestion, or esophageal malignancy. The remaining cases of AEF were caused by surgical complication, esophageal reflux, tuberculosis, traumatic false aneurysm, corrosive esophagitis, congenital anomaly, atherosclerotic disease, or instrumentation.
There is no standard treatment for secondary AEF. Herein we report a case of secondary AEF that developed from an infected thoracic aneurysm caused by an esophageal diverticulum. The patient underwent esophageal resection followed by esophageal-jejunum anastomosis and patch closure of the aorta followed by coverage of the omentum in a one-stage operation.
The patient, a 67-year-old woman, was admitted to Mie University Hospital because of anterior chest pain and intermittent melena. Eight months previously she had been diagnosed with an esophageal diverticulum during endoscopic examination of a gastric ulcer (Fig 1A).
Following this diagnosis, she was symptom free until she felt a severe chest pain and nausea. In the hospital, she began having massive hematemesis and melena and fell into hemorrhagic shock. The finding of emergent endoscopy demonstrated little bleeding from the site of the diverticulum. A three-dimensional computed tomography disclosed the presence of a saccular-type thoracic aneurysm protruding toward the lower esophagus (Fig 1B). Aortography confirmed the presence of a thoracic aneurysm of the descending thoracic aorta but did not demonstrate a fistulous connection with the esophagus. Because the intermittent episodes of melena persisted, an emergency operation was performed 4 days after admission. Based on consideration of a possible graft replacement of the descending aorta, a partial cardiopulmonary bypass was instituted between the femoral artery and right atrium through the femoral vein. The aneurysm was strongly adhered to the wall of the esophagus just above the diaphragm. The aorta was opened longitudinally close to the aneurysm. There was an entry of 3 x 2 cm of the aneurysm, and it was filled with a thrombus. The entry was patch-closed using a 1-mm Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) patch soaked in 0.1% rifampicin solution. The esophagus was resected at 3 cm proximal to the aneurysm and was dissected from the aorta at the site of the fistula (Fig 2).
The end of the esophagus was reconstructed by esophagojejunostomy. The site of the fistula and the esophagojejunostomy were covered with the omentum. The pathologic examination found inflammatory changes of the wall of the esophagus and the presence of an esophageal diverticulum. The patient’s recovery was uneventful, and the evaluation made before discharge showed satisfactory repair and function. At present, 55 months after the operation, the patient continues to do well.
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Fig 1. (A) Endoscopy showed the presence of an esophageal diverticulum 8 months before the admission. (B) Preoperative three-dimensional computed tomography findings demonstrated a saccular-type thoracic aneurysm protruding toward the esophagus.
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Fig 2. Operative schema: the entry of the aneurysm was closed using a prosthetic patch soaked in 0.1% rifampicin solution. Hatched area was removed and covered with omentum.
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Comment
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Primary AEF is usually caused by fistulization of an expanding atherosclerotic aneurysm into the esophagus or, less commonly, by erosion of a reflux-associated esophageal ulcer into the aorta [1]. In our patient, the esophageal diverticulum had been found 8 months before the admission. As we cannot tell exactly how long it took for the thoracic aneurysm to develop, we think that the esophageal diverticulum developed before the aneurysm and that the aneurysm was a mycotic aneurysm caused by diverticulitis. Sosnowik and colleagues [2] reported a case with photographic documentation of the earliest endoscopic features of AEF. They found two small esophageal diverticula at the same time they detected the aneurysm. Attention to early findings of AEF—external compression of the esophagus, traction diverticula, and small mucosal erosion—even if no active bleeding is present, may allow timely intervention. We have viewed an esophageal diverticulum as almost harmless, but in some cases it may be a cause of thoracic aneurysm, as in our patient.
The triad of midthoracic pain, sentinel arterial hemorrhage, and final exsanguination after a symptom-free interval has been termed Chiari’s triad. Once the diagnosis is made, treatment should proceed without delay as the latent interval between prodromal hemorrhage and exsanguination is unpredictable. Thus, early diagnosis and treatment are essential to a favorable outcome [3]. We fortunately operated on the patient 4 days after the sentinel hemorrhage and before the final exsanguination.
Intraoperatively, we found that the entry of the aneurysm was filled with a thrombus. Preoperative inflammatory indicators of the patient were normal, and the infection of the patient had been controlled by antibiotics. Therefore, it seems that the infectious lesion could be removed en bloc and completely. The prosthetic patch was attached from the intimal side of the entry of the aneurysm.
To ensure a successful outcome, the surgical procedure should follow established principles for managing an aortic aneurysm, an esophageal perforation, and a potentially infected mediastinum. The omentum has been previously shown to be very effective in combating infection. It seems that early aggressive management of the associated esophageal perforation by esophagectomy is of paramount importance [4]. Because the esophagus is notorious for poor healing, most surgeons have recommended esophageal resection and either primary or staged reconstruction of gastrointestinal continuity rather than risk esophageal leak after surgery, a commonly fatal complication [5].
To reconstruct the esophagus, it is usually necessary to use the colon as a conduit rather than the stomach because problems of blood supply, including arterial obstruction from ligation, twisting, stretching, or congenital absence, are the most common causes of necrosis and leakage after gastroesophagostomy [6]. Our approach to surgical repair of AEF led to a successful outcome. Our patient has been asymptomatic for 4 years already.
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References
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Dossa C.D., Pipions I.I., Shepard A.D., Ernst C.B. Primary aortoenteric fistula. Ann Vasc Surg 1994;8:208-211.
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Sosnowik D., Greenberg R., Bank S., Graver M. Aortoesophageal fistula: early and late endoscopic features. Am J Gastroenterol 1988;83:1401-1404.[Medline]
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Hollander J.D., Quick G. Aortoesophageal fistula: a comprehensive review of the literature. Am J Med 1991;91:279-287.[Medline]
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Oppell U.O., Groot M., Thierfelder C., Zilla P., Odell J.A. Successful management of aortoesophageal fistula due to thoracic aortic aneurysm. Ann Thorac Surg 1991;52:1168-1170.[Abstract/Free Full Text]
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Coselli J.S., Crawford E.S. Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft. J Vasc Surg 1990;12:269-277.[Medline]
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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
