Asian Cardiovasc Thorac Ann 1998;6:101-103
© 1998 Asia Publishing EXchange Pte Ltd
Surgical Treatment of Aortoesophageal Fistula
Gu Chun Jiu, MD,
Zhang Zhi Wei, MD,
Bao Wei Ke, MD,
Yan De Min, MD,
Yuan Yi Hua, MD,
Xiu Zong Yi, MD
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Department of Cardiac Surgery First Affiliated Hospital of China Medical University Shenyang, Liaoning, People's-Republic-of-China
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For reprint information contact: Gu Chun Jiu, MD Department of Cardiac Surgery First Affiliated Hospital of China Medical University 155 North Nanjing Street Heping District Shenyang, Liaoning 110001 People's Republic of China Tel: 86 24 386 3731 Fax: 86 24 386 2377
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ABSTRACT
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Aortoesophageal fistula is an uncommon and lethal clinical condition. We operated on 2 cases of aortoesophageal fistula between 1991 and 1996. The operations were uneventful. However, both patients died from fatal hemorrhage at 7 and 30 days postoperatively, respectively. The management of aortoesophageal fistula is still a challenging problem for cardiac surgeons.
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INTRODUCTION
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Aortoesophageal fistula (AEF) is an uncommon and lethal condition rendering surgical treatment very unsuccessful. There are only 4 cases of long-term survival according to the most recent literature.1 Ctereteko and Mok2 reported the first survival after surgical treatment of AEF from an esophageal foreign body in 1980. Most AEF patients die from uncontrollable postoperative infection and subsequent aortic hemorrhage. Sloop and colleagues3 reported 86 cases of AEF caused by esophageal foreign bodies; all of these patients died. Generally, AEF results from an esophageal foreign body, tumor, infection, or aneurysm. Usually the foreign body is a sharp object such as a piece of metal wire or bone although there are a few reported cases of AEF resulting from smooth objects. The mechanism of AEF formation has been postulated as either direct penetration or pressure necrosis of the esophageal wall causing mediastinitis and localized aortitis which results in fistula formation.
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PATIENTS AND METHODS
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Two cases of AEF caused by a foreign body in the esophagus were treated at our hospital between 1991 and 1996. The same surgical procedure was used in both cases.
TECHNIQUE
After thoracotomy, the proximal and distal segments of the aorta were exposed and taped. Initially, a temporary shunt was established. After cross-clamping the aorta above and below the affected section, the aorta was opened for exploration. The affected section of the aorta was removed with the intercostal arteries ligated, while the lower branches were managed carefully to avoid the risk of postoperative paralysis. A graft of 2 to 2.5 cm in diameter was selected for replacement of the resected segment of aorta. We placed 3 or 4 interrupted mattress sutures of pledgetted polypropylene at the posterior wall, followed by continuous suturing to insure safety. The proximal end was anastomosed first. When both anastomoses were finished, the distal clamp was released first for de-airing. When both clamps were released, the anastomoses were checked carefully for signs of bleeding. After aortic bleeding was controlled, the thoracic esophagus was resected. The proximal and distal ends were closed and covered with parietal pleura leaving both residual ends outside the pleural cavity that was then irrigated thoroughly.
CASE 1
A 21-year-old man was admitted to a local hospital in 1991 complaining of retrosternal pain. The patient had swallowed metal wires. Chest radiograph showed metal wires in the middle segment of the esophagus, the stomach, and colon. The patient was observed closely without further treatment until he suffered massive hematemesis 4 days later. He was transferred to our hospital where soon after admission he suffered a second massive hematemesis of approximately 500 mL. The patient was pale and he was found to have tachycardia with a blood pressure of 90/60 mm Hg. Repeated chest radiography confirmed a metal foreign body in the middle segment of the esophagus. An emergency operation was performed immediately through a left thoracotomy. Exploration revealed a dense adherence between the esophagus and the descending aorta precluding further dissection. A temporary shunt across the affected section of the aorta was established and after heparinization, the aorta was cross-clamped above and below the shunt. The affected aorta was opened digitally to reveal a 7-mm perforation of the posterior wall with surrounding pus formation. Several V-shaped metal wires were removed. The aortic perforation was repaired with a Dacron patch measuring 2 x 3 cm and the esophagus was sutured. Massive doses of antibiotics were administered postoperatively. However, a high fever (39°C) occurred from the 5th postoperative day with leukocytosis. On the 7th postoperative day, the patient suddenly became restlessness after a small amount of nasal bleeding. Massive hematemesis followed and he died instantly.
CASE 2
A 26-year-old man was admitted because of hematemesis and melena. The patient had swallowed metal wire 10 days and 4 days earlier in an attempted suicide. He had dysphagia and retrosternal pain. Chest radiograph showed lodgment of crossed metal wires in the middle segment of the esophagus. An emergency operation performed through a left thoracotomy revealed that the posterior wall of the descending aorta was densely adherent to the mid portion of the esophagus. The esophagus was entered revealing a 0.5-cm perforation in the descending aorta and a similar hole in the esophagus. The aortic wall was edematous and approximately 1 cm thick. The esophagus was primarily repaired by covering with normal tissue. The affected aorta was resected and replaced with a 4-cm long Dacron graft under a temporary shunt. The patient had a normal body temperature and white cell count, and was discharged on the 29th postoperative day. He was hospitalized again 2 days later due to hematemesis. Soon after admission, he died suddenly from another episode of massive hematemesis.
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DISCUSSION
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Aortoesophageal fistula is very uncommon clinically, although Baron and colleagues4 reported that 12% of thoracic aneurysms can perforate into the esophagus forming an AEF. Very few of these patients receive surgical treatment because the majority die quickly from gastrointestinal bleeding. Yonago and colleagues5 reported the long-term survival of a patient with AEF managed by aortic graft replacement in 1969. The first successful surgical treatment of AEF caused by an esophageal foreign body was reported by Ctereteko and Mok2 in 1980. In 1983, Synder and Crawford6 reported 2 cases with a successful surgical outcome after repair of AEF resulting from thoracic aneurysm. In our 2 cases of AEF caused by metal wire in the esophagus, the operation was performed uneventfully but both patients died from uncontrollable postoperative hemorrhage.
Most patients with AEF have thoracic pain prior to a hemorrhage. For AEF caused by a foreign body, the latent period between swallowing the foreign body to signal hemorrhage varies from 6 hours to 4 years. Many AEF patients die from gastrointestinal bleeding without a definite diagnosis. Plain chest radiography is a simple and safe diagnostic technique. Other noninvasive techniques include computed tomography and magnetic resonance imaging that can specify the site and size of the aneurysm and the presence of dissection and esophageal perforation. Esophagoscopy and aortography may also be applied. Esophagoscopy can exclude a gastrointestinal disorder when the diagnosis is unclear but the test can be very dangerous when an AEF is present. Esophagoscopy may dislodge a thrombus and precipitate further bleeding.
Surgery should be performed without delay once a definite diagnosis has been made of AEF or perforation of the esophagus by a foreign body. A left thoracotomy through the 4th intercostal space may give the best access to the site of an AEF as well as control of the aorta above and below the fistula. We consider that simple removal of the fistula and direct suturing of perforations should be performed only as a temporary measure. Primary repair of the esophagus with aortic graft replacement is not ideal because of the risk of residual infection and subsequent hemorrhage. We recommend excision of the potentially infected aorta and replacement with a Dacron graft, thoracic esophageal resection with cervical esophagostomy, proximal stomach closure and gastrostomy. The distal circulation during aortic cross-clamping may be maintained by measures that include hypothermia, left atrium-to-distal vessel bypass, femoral artery-to-vein bypass, and a temporary shunt between the distal and proximal aorta. Usually, when the temporary shunt is established, a graft is sutured between the proximal and distal aorta. This is time consuming and occasionally bleeding may occur after graft removal. We modified this method with direct aortic cannulation across the two segments. We have performed the technique in 10 cases of aneurysm surgery where it has proven to be easy to use and timesaving.
Combined antibiotic therapy should be used before, during, and after operation. Body temperature and white cell counts should be monitored carefully and chest radiography should be repeated. Reinforcement of the suture line with pedicled flaps of adjacent normal tissue, including parietal pleural, gastric fundus, pericardium, omentum, intercostal or diaphragmatic muscle, and occasionally lung, is beneficial for the prevention of graft infection and false aneurysm formation. Once infection occurs, the graft should be removed as soon as possible. Bypass between the ascending and abdominal aorta should be constructed via a median sternotomy and a median laparotomy without entering the infected area.
Aortoesophageal fistula is still a challenging and complex problem for surgeons. There are few cases of success so far. We hope our limited experience may contribute to improved surgical treatment of this disorder.
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REFERENCES
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Wong JWW, Sivathasan C, Ng EH, Wong WK. Ruptured aortic aneurysm esophageal fistula. Asian Cardiovasc Thorac Ann
1995;3:128–30.
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Ctereteko G, Mok CK. Aorta-esophageal fistula induced by a foreign body. J Thorac Cardiovasc Surg
1980;80:233–5.[Abstract]
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Sloop R, Thompson J. Aorta-esophageal fistula: report of a case and review of the literature. Gastroenterology
1967;53:768–77.[Medline]
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Baron RL, Koehler RE, Gutierez FR, et al. Clinical and radiographic manifestations of aorto-esophageal fistulas. Radiology
1981;141:599–605.[Abstract/Free Full Text]
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Yonago RH, Iben AB, Mark JB. Aortic bypass in the management of aorto-esophageal fistula. Ann Thorac Surg
1969;7:235–7.[Medline]
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Synder DM, Crawford ES. Successful treatment of primary aorta-esophageal fistula resulting from aortic aneurysm. J Thorac Cardiovasc Surg
1983;85:446–57.
TOP
ABSTRACT
INTRODUCTION
