Surgical strategy of esophageal resection and reconstruction for aortoesophageal fistula

Abstract

Aortoesophageal fistula is a critical and life-threatening disease. The cardiovascular strategy for graft replacement has been widely discussed. However, the surgical strategy of esophageal resection and reconstruction for aortoesophageal fistula has rarely been discussed. The objective of this study is to establish a surgical strategy and procedure of esophageal resection and reconstruction for aortoesophageal fistula. Eleven patients with aortoesophageal fistula who underwent aortic graft replacement and esophagectomy between 2008 and 2015 at Kobe University Hospital were enrolled in this study. Patient characteristics, operative methods, and clinical outcomes were obtained by retrospective chart review. All 11 patients underwent graft replacement, esophagectomy, and omental wrapping. Ten esophagectomies were simultaneously accomplished in the same operative field as aortic graft replacement. Seven patients underwent subtotal esophagectomy from a left thoracotomy, and three patients underwent upper hemiesophagectomy from a median sternotomy. The other patient underwent staged esophagectomy from a right thoracotomy. Seven of 11 patients (63.6%) successfully underwent staged esophageal reconstruction. Pedicled jejunal transfer with supercharge and superdrainage were performed in six patients, and ileocecal reconstruction was performed in one patient. Median survival time in the patients with esophageal reconstruction was 21 months while that in the patients without esophageal reconstruction was 10 months. Six of 7 patients (85.7%) who underwent esophageal reconstructions were alive. Our surgical strategy for aortoesophageal fistula, which includes simultaneous graft replacement and esophagectomy in the same operative field and staged reconstruction by pedicled jejunal transfer to ensure omental wrapping, is feasible and promising.

Risk Factors for Mortality in Patients with Aortoesophageal Fistula Related to Aortic Lesions

“…Surgery for AEF is performed to repair the fistula and control bleeding and infection [ 20 , 21 ]. The approaches include extra-anatomical bypass or in situ replacement with grafts, as well as repair or resection of esophageal fistula with primary or secondary reconstruction [ 1 , 22 , 23 ].…”

Successful Surgical Strategy for Graft-esophageal Fistula After Total Arch Replacement : A Case Report.

“…Four months after the operation, supra-sternal jejunal bypass was successfully performed (8). At the 3year follow-up, the patient showed no signs of infection without antibiotic therapy (Fig.…”

Current indications for the intrathoracic transposition of the omentum

“…A particular situation is the development of an aorto-esophageal fistula, which has a very high immediate fatal outcome potential while surgical repair is extremely challenging due to the complexity of the lesions and the presence of infection. The most succesfull strategy seems to be the one proposed recently by Nakamura and colleagues (2017) consisting in emergency graft replacement of the ruptured/perforated aorta and esophagectomy with mediastinal debridement to achieve local control of sepsis, as well as OP in order to protect the vascular graft which is implanted in a septic area [46]. Endovascular repair may allow an immediate temporary controle of the bleeding, which is usefull in the patients with haemorrhagic shock while an esophageal reconstruction in a later stage is possible if there are no other complications and the biological status of the patient allows another major procedure [46–48].…”