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Ann Thorac Surg 2004;77:2217-2218
© 2004 The Society of Thoracic Surgeons

Case report

Diagnosis and management of aortoesophageal fistula caused by a foreign body

Giuseppe S. Sica, MD, PhD*a, Veronica Djapardy, MDa, Stephen Westaby, MD, PhDb, Nicholas D. Maynard, MS, FRCSa

a Department of Surgery, Oxford, United Kingdom
b Cardiothoracic Unit, The John Radcliffe Hospital, Oxford, United Kingdom

Accepted for publication June 2, 2003.

* Address reprint requests to Dr Sica, Department of Upper GI Surgery, Level 2, The John Radcliffe Hospital, Headley Way, Headington Oxford OX3 9DU, UK
e-mail: giuseppesica{at}libero.it


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Aortoesophageal fistula is a rare cause of gastrointestinal hemorrhage often resulting in mortality. A case of aortoesophageal fistula caused by a swallowed fish bone leading to respiratory arrest is reported. The clinical presentation was unusual. The successful treatment required the use of hypothermic circulatory arrest.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Aortoesophageal fistula is a rare complication of foreign body ingestion. The typical presentation of aortoesophageal fistula is chest pain, swallowing pain, sentinel hematemesis, and massive upper gastrointestinal hemorrhage. Unfortunately, despite advanced therapeutic interventions mortality from aortoesophageal fistula remains high.

We present the case of a previously healthy 57-year-old woman urgently referred to a district hospital with central chest pain after swallowing a fish bone. The clinical examination, blood tests, electrocardiogram, and chest roentgenogram were unremarkable. The patient's symptoms settled, and she was sent home. A week later she represented to the same hospital because of worsening chest pain that radiated to the jaw.

Clinical examination remained unremarkable, but blood tests showed a white blood cell count of 16.29 and C-reactive protein of 103. Chest roentgenogram showed a line of gas tracking up the right heart border to the neck. A diagnosis of esophageal perforation leading to mediastinitis and pneumomediastinum was made.

The patient was initially managed with broad-spectrum antibiotics and analgesia, but she deteriorated and suddenly had a respiratory arrest. She was resuscitated, but attempted endotracheal intubation proved difficult. Bronchoscopy showed a narrowing of the trachea beyond the endotracheal tube. At this stage it was thought that a localized perforation of the esophagus had caused a superior mediastinal abscess resulting in compression of the trachea. A computed tomographic scan was performed and she was urgently transferred to the specialist center.

A pre-contrast computed tomorgraphic scan (Fig 1) showed a gas-filled collection around the esophagus in the superior mediastinum, leading to significant tracheal narrowing. In retrospect there was radiologic intravenous contrast in the abscess cavity (Fig 2); however, because she remained hemodynamically stable, aortic involvement was not anticipated.



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  		Fig 1. Pre-contrast computed tomographic scan showing collection in the posterior mediastinum compressing the trachea.

 


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  		Fig 2. Post-contrast computed tomographic scan showing free contrast in the abscess cavity.

 
A standard right posterolateral thoracotomy operation was performed to gain access to the superior mediastinum and the esophagus. The aim was to drain the abscess and decompress the airway and then manage the esophageal perforation. After incision of the thickened mediastinal pleura, frank pus was drained followed rapidly by arterial blood at high pressure. The thoracotomy was extended anteriorly, the pericardium was opened, and the patient was placed on cardiopulmonary bypass through the ascending aorta and the right atrium. The systemic temperature was lowered to 18°C for hypothermic circulatory arrest. The esophagus was mobilized above and below the abscess and was lifted away from the aorta. This exposed a 1-cm necrotic defect in the distal aortic arch, just distal to the origin of the left subclavian artery. After debridement, the 3 x 2 cm aortic defect was closed with an aortic homograft patch sewn in place with continuous 3-0 polypropylene. No other foreign material was used. After rewarming, cardiopulmonary bypass was recommenced with rewarming. There was no difficulty in separating from perfusion. Esophagectomy was then carried out, stapling the esophagus at the thoracic inlet and at the hiatus.

The patient was admitted to the intensive care unit where she gradually improved. Three days later she returned to the operating room for a formation of end cervical esophagostomy and insertion of a needle catheter jejunostomy for nutritional support. Subsequent recovery was uneventful, and she was transferred to the surgical ward after 4 days. She was discharged home on postoperative day 20.

Four months later she underwent reconstructive surgery with a gastric tube pulled up substernally through the anterior mediastinum. Twelve months later she remains well and is swallowing normally.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Aortoesophageal fistula is rare. Most of the cases are attributable to aneurysms of the ascending aorta, erosive malignant neoplasm, esophago-gastric reflux, foreign body ingestion, lye exposure, and therapeutic intervention.

Fish bone as a source of esophageal foreign body is common in the Asian community [1]. The most common site of impaction is the cervical esophagus at the level of the cricopharyngeus, followed by the thoracic esophagus at the level of the aortic arch. The presentation of aortoesophageal fistula includes chest pain, swallowing pain, sentinel hematemesis, and massive upper gastrointestinal hemorrhage [2].

In our case the initial clinical presentation of the patient was unclear. We believe that the aortic perforation was due to a mycotic abscess and subsequent necrosis of the aortic wall. Because of the difficulties with ventilation, the patient was urgently taken to the operating room for surgery before we were aware of the potential vascular injury. We did not suspect an aortic injury at this stage; therefore a right posterolateral thoracotomy was performed. Control of the aortic hemorrhage from the right chest was difficult. The use of hypothermic cardiac arrest provided a bloodless field and the repair was successful.

Sloop and Thompson [3] reviewed 81 cases of aortoesophageal fistula for more than 144 years and reported 100% mortality. The first successful operation was recorded in 1980 [4]. The surgeons cross clamped the thoracic aorta and the patient survived, although this procedure carries a significant risk of paraplegia. Furthermore, this method of arresting hemorrhage has been unsuccessful in many other patients. Use of hypothermic circulatory arrest may offer an improvement in the management of this lethal condition.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Lim C.T., Quah R.F., Loh L.E. A prospective study of ingested foreign bodies in Singapore. Arch Otolaryngol Head Neck Surg 1994;120:96-101.[Abstract/Free Full Text]
  2. Chiari H. Uber fremdkorperverletzung des oesophagus mit aortenperforation. Berl Klin Wschr 1914;51:7-9.
  3. Sloop R.D., Thompson J.C. Aorto-esophageal fistula: report of a case and review of the literature. Gastroenterology 1967;53:768-777.[Medline]
  4. Ctercteko G., Mok C.K. Aorto-esophageal fistula induced by a foreign body: the first recorded survival. J Thorac Cardiovasc Surg 1980;80:233-235.[Abstract]



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