Endovascular stent graft repair of aortogastric fistula caused by peptic ulcer after esophagectomy: A case report

Abstract

Rationale: Aortogastric fistula (AGF) is a rare but devastating clinical complication after esophagectomy. In a recent report, nearly all AGF patients died of massive hemorrhage or aspiration of massive hematemesis. Therefore, timely appropriate treatment of AGF remains a challenge.Herein, we report a case of AGF that resulted from peptic ulceration after esophagectomy and was successfully treated with endovascular stent graft placement.

Patient concerns: A 59-year-old man had undergone video-assisted thoracoscopic esophagectomy for squamous cell carcinoma and esophageal reconstruction using a gastric tube 14 months previously. He suddenly experienced massive hematemesis and unstable circulatory dynamics, Infusion was performed to treat critical hemorrhagic shock but was ineffective. We informed the patient and his family members of the situation, and once written informed consent to treatment was provided, we rushed him to the operating room.

Diagnoses: Contrast medium permeated into the gastric cavity through a fistula between the abdominal aorta and gastric tube at the 11th thoracic level, Based on this, we made a diagnosis of AGF resulting from a peptic ulcer, and this diagnosis was further confirmed by high pressure angiography combined with computed tomography (CT) imaging.

Interventions: An endovascular stent graft was placed under the guidance of digital subtraction angiography and followed by antibiotic therapy to prevent infection and proton pump inhibitor therapy to inhibit gastric acid secretion.

Outcomes: The patient recovered uneventfully after the procedure. Four months after surgery, the patient died of organ failure caused by retroperitoneal lymph node metastasis and multiple intrahepatic metastases, with no postoperative bleeding linked to the endovascular stent graft repair.

Lessons: Our case supports the notion that endovascular stent graft repair is a feasible alternative in treatment of AGF with several advantages in addition to surgical intervention, although more such cases should be collected and analyzed in the future to corroborate our observations.

Figure 1

A peptic ulcer is observed by gastrointestinal endoscopy on the posterior wall of the distal part of the gastric tube.

Figure 2

Emergency abdominal aortography (A) and CT (B) revealing remarkable extravasation of contrast medium that flowed out of the gastric tube. CT = computed tomography.

Figure 3

Aortography after stent graft placement around the fistula revealing hemostasis.

Figure 4

Changes in Hb levels before and after stent implantation in the patient. Hb = hemoglobin.

Figure 5

Contrast-enhanced CT showing no evidence of extravasation. CT = computed tomography.