| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2006;82:1117-1119
© 2006 The Society of Thoracic Surgeons
a Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
b Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
Accepted for publication January 24, 2006.
* Address correspondence to Dr van Hillegersberg, University Medical Center Utrecht, Department of Surgery (G04.228), Heidelberglaan 100, Utrecht, 3584 CX the Netherlands (Email: r.vanhillegersberg{at}azu.nl).
 |
Abstract |
|---|
 Top Abstract IntroductionCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
A previously healthy 31-year-old man presented at our emergency department with severe hematemesis. His complaints had commenced 8 days earlier after swallowing a chicken bone. The complaints consisted of mild thoracic pain, dysphagia, general malaise, and coughing. These subtle clinical symptoms were initially diagnosed as pneumonia for which he received antibiotics from his general practitioner. On admission the patient was hemodynamically stable and an esophago-gastroscopy was done showing a tear in the distal esophagus presumed to be a Mallory-Weiss lesion, which was treated by adrenaline injection.
The next day the patient became hemodynamically unstable and rapidly developed severe swelling of the neck with breathing difficulties. An emergency tracheotomy was performed and computed tomographic angiography revealed a mass with air in the mediastinum and contrast leakage from the aorta 2 cm distal to the left subclavian artery (Fig 1). The diagnosis of AEF was apparent, and an endovascular thoracic aortic stent-graft was immediately placed (TAG 28-10 [W. L. Gore & Assoc, Flagstaff, AZ]) with intentional overstenting of the left subclavian artery. Intraoperative angiography showed complete exclusion of the fistula and no endoleaks.
|
|
Subsequently the patient had an uneventful postoperative course. At present, 8 months postoperatively, the patient is doing well.
|
Comment |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
Bleeding Complication of AEF
The widely accepted treatment for AEF is thoracotomy with aortic graft interposition, followed by reconstruction of the esophagus. This procedure shows extremely high mortality and morbidity rates due to the poor condition of the patients at the time of surgery [3, 4]. Furthermore, there is a significant chance of paraplegia. Endovascular stent placement for AEF has been described with good results [1, 5]. It stops the bleeding and provides the opportunity to stabilize and optimize the patient's condition before further treatment. It is debated however, whether endovascular stenting can be seen as definitive treatment or only as a bridge to further aortic surgery, because graft material is placed in an infected area without any adjunctive procedures like omental plasty [5, 6]. Although short-term results of endovascular treatment of AEF are promising, there is no knowledge about the long-term outcome. In this case, our patient was prescribed oral antibiotics with close surveillance for signs of infection. He stopped taking his prescribed medication, but there are no signs of infection 8 months after stenting. Still, as the patient is such a young age, stenting is considered a temporarily life-saving solution, and the patient will undergo open aortic surgery in the near future.
Management of Esophageal Perforation
With respect to esophageal perforation, primary closure and drainage is advocated if the perforation is diagnosed within 24 hours [3, 7]. In this patient the perforation had existed for more than a week, resulting in severe mediastinitis and esophageal necrosis. Therefore primary repair was deemed unsuitable and the risk of residual leakage of the repair with continuing mediastinitis was unacceptably high. Esophageal resection and drainage of the mediastinum were considered the best option. The timing of the esophagectomy depended on whether or not the patient could be stabilized after such severe hemorrhage.
Early secondary construction using a gastric tube was considered optimal because of sufficient improvement in the patient's general condition within a week and subsidence of the infiltration in the mediastinal space. The gastric tube construction is generally delayed for more than 6 weeks until the patient has fully recovered, but then positioning of the tube through the original esophageal bed is no longer possible.
This case of a young patient, who survived an AEF after ingestion of a chicken bone, presents the considerations encountered in diagnostics, and especially the choice and timing of therapeutic options. The excellent clinical results after short-term follow-up seem to indicate that these choices were prudent. Nonetheless, we wish to emphasize that managing each case of an aortoesophageal perforation demands an individualized approach and an experienced surgical team.
|
References |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  H. Eggebrecht, R. H. Mehta, A. Dechene, K. Tsagakis, H. Kuhl, S. Huptas, G. Gerken, H. G. Jakob, and R. Erbel Aortoesophageal Fistula After Thoracic Aortic Stent-Graft Placement: A Rare but Catastrophic Complication of a Novel Emerging Technique J. Am. Coll. Cardiol. Intv., June 1, 2009; 2(6): 570 - 576. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. F. Ford and M. A. Farber Role of Endovascular Therapies in the Management of Diverse Thoracic Aortic Pathology Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 134 - 143. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
