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Case Reports
. 2022 Jun 8:9:916006.
doi: 10.3389/fsurg.2022.916006. eCollection 2022.

Salvaged, Staged, and Safer Management of Aortoesophageal Fistula and Mediastinitis After Removing a Pork Bone: A Case Report

Yan Ge  1 , Ayinuer Tuerdi  2 , Xinming Yang  2 , Jingqun Tang  3 , Quanming Li  4
Affiliations
Case Reports

Salvaged, Staged, and Safer Management of Aortoesophageal Fistula and Mediastinitis After Removing a Pork Bone: A Case Report

Yan Ge et al. Front Surg. .

Abstract

Aortoesophageal fistula (AEF) caused by esophageal foreign body (EFB) ingestion is a life-threatening condition with a very low survival rate. However, the optimal management strategy remains undetermined. Here, we describe our successful management of a patient with AEF and mediastinitis. A 36-year-old man developed persistent chest and back pain and vomited fresh blood three days after removal of a pork bone in the esophagus under endoscopy in a local hospital. Computed tomography (CT) confirmed bilateral pulmonary infections, mediastinitis, and fistula of the aortic arch. After a multidiscipline discussion, a comprehensive staged strategy was made including salvaged thoracic endovascular aortic repair (TEVAR) to control fatal bleeding, adequate mediastinal debridement, drainage with cervical incision, and video-assisted thoracoscopic surgery, as well as jejunostomy to prevent nasal or gastrostomy reflux from aggravating the mediastinal infection. Furthermore, systematic personalized nutrition support and antibiotics were provided. The patient recovered well and has survived for 50 months until now. Careful assessment should be made with CT to ascertain the risk of AEF before and after the removal of EFB. A salvaged staged strategy of TEVAR with adequate mediastinal debridement and drainage in a less invasive approach may be a safer alternative for AEF patients with infections caused by EFB.

Keywords: aortoesophageal fistula; esophageal foreign body; mediastinitis; salvaged staged strategy; thoracic endovascular aortic repair; video-assisted thoracoscopic surgery.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Preoperative examinations. (A) Computed tomography angiography (CTA): coronal view of mediastinitis and aortoesophageal fistula. Mediastinitis and gas accumulation with the green circle. The white arrow points to the leakage of contrast from the aorta, indicating a break in the aortic wall, within a small red circle. (B) Three-dimensional CT showed a break in the aortic wall (big red circle points to the aortic breakage).
Figure 2
Figure 2
Postoperative images. (A and B) different views of three-dimensional computed tomography angiography (CTA): complete sealing of the break in the aortic wall after thoracic endovascular aortic repair (TEVAR). (C,D) Transverse view: complete sealing of the break in the aortic wall, no contrast agent extravasation was observed around the stent after TEVAR; bilateral pleural effusions were seen mainly on the right side. (E,F) Axial contrast-enhanced CT image after mediastinal debridement and drainage with cervical incision and video-assisted thoracoscopic surgery: the stent and drainage tube were observed clearly, with no fluid on both sides of the chest.
Figure 3
Figure 3
Postoperative upper digestive tract iodine angiography. (A,B) Esophageal walls were intact, without contrast agent leakage.
See this image and copyright information in PMC

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