Proposed management protocol for ingested esophageal foreign body and aortoesophageal fistula: a single-center experience

Abstract

Objective: Aortoesophageal fistula (AEF) is a life-threatening complication of foreign body ingestion. The primary objective of this study was to describe a new management protocol for infected AEFs, which combines endovascular stent grafting and mediastinal drainage using video-assisted thoracoscopic surgery (VATS).

Methods: The authors analyzed the clinical data of 22 patients with ingested foreign bodies retrospectively, developed a classification system based on multidetector computed tomography (MDCT) findings for esophageal injuries induced by foreign body ingestion, and used this system and the clinical presentation to guide treatment.

Results: Depending on the MDCT findings, the esophageal injuries were divided into four grades: Grade I, non-penetrating injury (six patients); Grade II, penetrating injury with minimal infection (five patients); Grade III, potential AEF (five patients); and Grade IV, definite AEF (six patients). When a foreign body was visible on MDCT, a distance of ≤ 2 mm between the foreign body and aortic wall indicated potential or definite AEF. When no foreign body was visible, a typical clinical presentation, especially sentinel hemorrhage, and MDCT findings were used to establish the diagnosis. Only three Grade IV patients who underwent open surgery died of severe hemorrhage within 24 h postoperatively. The others patients had a good outcome with different treatment.

Conclusions: The authors' experience indicates that MDCT was useful to classify esophageal injuries caused by foreign body ingestion which predicted the risk of AEF; endovascular stent grafting and VATS-guided mediastinal drainage would be a safe and minimally invasive method for treating patients with AEF and has the potential for improved treatment options for AEFs.

Keywords: Aortoesophageal fistula; endovascular stenting; esophageal foreign body; video-assisted thoracoscopic surgery.

Figure 1

MDCT showing space between the foreign body and aortic wall. A and B: in patients with Grade I, non-penetrating esophageal injury. C, D: Grade II injuries, penetrating esophageal injury, > 2 mm distance between the foreign body and aortic wall.

Figure 2

Foreign bodies stuck to the aortic wall (A, B) and severe mediastinitis (C, D; white arrows) in patients with Grade III injuries.

Figure 3

MDCT subtypes of AEFs Grade IV injuries. A, B: Pseudoaneurysm and AEF, with a diverticulum (white arrow) on the medial wall of the aortic arch, surrounded with inflammatory tissue. C: Fibrous encapsulation and AEF, with a swollen soft-tissue mass (white arrow) between the esophagus and descending aortic wall, whose boundary on the right side is unclear. D: Mediastinal abscess and AEF in the plane of the inferior pulmonary vein. A contrast-enhanced scan shows the fistula on the descending aortic (DA) wall, and the contrast agent flows into the false aneurysm (FA). Inflammatory and necrotic tissue is seen around the esophagus and the descending aorta, with gas formation and left pleural effusion.

Figure 4

A: CT angiography images. AEF with inflammatory exudate surrounding the descending aorta (diameter 5.4 mm). B: An aortic pseudoaneurysm at the anterior wall of the descending aorta at the lower edge of thoracic vertebrae 10 (arrow). C, D: Aortic endovascular stent graft implantation to close the AEF (arrow).