Aortoesophageal fistula: value of in situ aortic allograft replacement

Abstract

Purpose: The purpose of this report is to describe our experience in management of aortoesophageal fistulas (AEF) with special emphasis on the value of in situ aortic allograft replacement.

Patients: Nine patients presenting with AEF were observed between May 1988 and April 2002. There were 4 men and 5 women with a mean age of 54.3 years (range, 32-77 years). Six patients presented secondary AEF after aortic repair. Two patients presented primary AEF after rupture of an atherosclerotic aneurysm into the esophagus. In the remaining patient, AEF was caused by swallowing a fishbone. In 6 cases involving true AEF with a direct communication between the aorta and esophagus, massive exsanguinating hematemesis occurred. It was usually preceded by minor sentinel bleeding. Two patients presented esophagoparaprosthetic fistula (EPPF). One patient presented primary AEF that was contained by a large thrombus in the communication. The clinical picture in these 3 patients involved severe sepsis without hemorrhage.

Results: Two patients died as a result of massive hemorrhage before assessment and surgical treatment could be undertaken. One 77-year-old woman presenting EPPF refused to undergo surgery and died because of infection. The remaining 6 patients underwent surgical treatment with various outcomes. One man died during thoracotomy caused by exsanguinating hemorrhage. One woman presenting EPPF was treated by exclusion followed by ascending aorta to abdominal aorta bypass grafting, removal of the prosthesis, esophageal exclusion, and directed esophageal fistula. She died of infection. The other 4 patients were treated by in situ aortic allograft replacement. The damaged esophagus was repaired by using the Thal technique in 1 patient. In the remaining 3 cases subtotal esophagectomy was performed in association with cervical esophagostomy, ligation of the abdominal esophagus, gastrostomy, and jejunostomy. One patient died of sepsis during the first 24 hours after the operation. The other 3 patients underwent secondary esophagoplasty and survived with no further sign of infection. Mean duration of follow-up in the survivor group was 53 months (range, 15-95 months). Overall 6 patients, including 3 that did not undergo surgical treatment, died and 3 patients survived.

Conclusion: Our experience confirms that AEF is a rare but catastrophic disorder. In situ allograft replacement usually in association with subtotal esophagectomy appears to be an excellent salvage modality whenever emergency surgery is feasible.

FIGURE 1. Esophageal contrast study showing esophageal narrowing associated with extravasation of contrast material in a patient presenting an aortoesophageal fistula induced by an ingested fishbone.

FIGURE 2. Esophageal contrast study showing extravasation of contrast material around the nearby prosthesis in a patient presenting an esophagoparaprosthetic fistula.

FIGURE 3. Computed tomography showing a large gas effusion around the prosthesis in a patient presenting esophagoparaprosthetic fistula.

FIGURE 4. Computed tomography showing the presence of air bubbles in mural thrombus in an aneurysm of the thoracoabdominal aorta ruptured into the esophagus.

FIGURE 5. Computed tomography showing a small false aneurysm located in the distal segment of the aortic arch (same patient as in Fig. 1). The fishbone that caused the aortoesophageal fistula can be seen inside the aneurysm (arrow).

FIGURE 6. Computed tomography showing adherence of the esophagus to the prosthesis and presence of mural thrombus within the prosthesis (same patient as in Fig. 3).