Successful management of an aortoesophageal fistula caused by a fish bone – case report and review of literature

Abstract

We report a case of aortoesophageal fistula (AEF) caused by a fish bone that had a successful outcome. Aortoesophageal fistula is a rare complication of foreign body ingestion from which few patients survive. Over one hundred cases of AEF secondary to foreign body ingestion have been documented but only seven, including our case, have survived over 12 months. Treatment involved stabilising the patient with a Sengstaken-Blakemore tube and insertion of a thoracic aortic endovascular stent-graft. Unfortunately the stent became infected and definitive open surgical repair involved removing the stent, replacing the aorta with a homograft and coverage with a left trapezius flap while under deep hypothermic arrest. Case presentationA 59 year old man with no prior medical history, presented to a peripheral hospital emergency department with sharp pain retrosternally after eating fish the previous day. He was able to swallow fluids and soft diet but with odynophagia. A cardiac cause was ruled out and a barium swallow was organised as an outpatient. The patient was discharged home. Day five after presentation he had frank haematemesis and some malaena. He was haemodynamically stable with a haemoglobin at 130 g/L and admitted to the general surgical ward. The next day he had another large haematemesis and proceeded to urgent upper gastrointestinal (GI) endoscopy where a fish bone was seen protruding from an ulcerated area in the oesophagus, 24 cm from the teeth. There was some active bleeding after the fish bone was removed. A SengstakenBlakemore tube (SBT) was inserted and the oesophageal and gastric balloons inflated. This controlled the bleeding and the patient was admitted to the intensive care unit (ICU) with intravenous (IV) antibiotics as well as an ongoing blood transfusion. Overnight there was no further bleeding but the patient had evidence of sepsis with a high fever and hypotension despite no evidence of blood loss. He required inotropic support.The following morning, the patient was transferred to the ICU at our centre. The SBT balloons were deflated and patient observed. There was no evidence of blood loss over the ensuing 24 hours so the SBT was removed. Five hours later, he had a massive haematemesis causing hypovolaemic shock with cardiac arrest requiring reinsertion and reinflation of the SBT, massive transfusion and cardiopulmonary resuscitation. Once stabilized, a computed tomography (CT) angiogram was performed. This dem-

Diagnosis and treatment of 32 cases with aortoesophageal fistula due to esophageal foreign body

“…3 Only seven cases with AEF due to foreign body had survived over one year until 2009. 4 Even though the methods of diagnosis and treatment have been improved recently, the morbidity and mortality rate is still not markedly reduced.…”

Fístula aortoesofágica

“…La naturaleza del cuerpo extraño varía de acuerdo con la edad del paciente; en los adultos se reportan los huesos de animales, especialmente espinas de pescado, y otros como prótesis dentales o elementos de trabajo; en los niños se reportan monedas, pilas, agujas, y el 80% de los casos en niños se presenta en menores de 3 años; la lesión es más grave cuando se trata de pilas con material corrosivo, pues se reconocen distintas variedades con una patogénesis similar: derramamiento del corrosivo, absorción del tóxico, necrosis por presión y quemadura eléctrica; se reconoce mayor morbimortalidad con aquellas compuestas por hidróxido de sodio y potasio [13,[21][22][23].…”

Aorto-oesophageal fistula and aortic pseudoaneurysm caused by a swallowed fish bone

“…5 Perforation of the oesophagus with aortic fistulation is usually fatal. 6 Kelly et al 7 reviewed over 100 documented cases of aorto-oesophageal fistula secondary to foreign body ingestion, and noted that only seven had survived 12 months. Conservative treatment of aorto-oesophageal fistula results in a 60% in-hospital mortality rate and zero late survival, whereas conventional surgical treatment is reported to have an in-hospital mortality of nearly 40%.…”