Aortoesophageal Fistula Induced by Foreign Bodies Ming-Ho Wu, MD, and Wu-Wei Lai, MD Division of Chest Surgery, Department of Surgery, National Cheng-Kung University Hospital, Tainan, Taiwan, Republic of China

Two patients with aortoesophageal fistula induced by foreign bodies were surgically treated during a period of 10 years. The first patient was surgically treated through a right thoracotomy, which failed on account of exsan- guination. In the second patient, a Sengstaken- Blakemore tube was inserted for esophageal tamponade. The aorta was successfully repaired through a left thora-

oreign bodies may erode the esophagus and cause it to F rupture into the aorta. Further, an inappropriate esophagoscopic extraction of a foreign body may also cause a similar condition. High mortality still accompanies these cases [l-61. To date, only 1 patient with aortoesoph- ageal fistula induced by a foreign body has survived for a long time as recorded by Ctercteko and Mok in 1980 [l]. One of our 2 patients survived the operation performed to treat the fistula. Their clinical courses and treatments are reviewed and discussed below.

Case Reports Patient 1 A 35-year-old male sailor was admitted on July 12, 1980. He had had fever, dysphagia, and substernal pain of 5 days’ duration after ingesting lobster. On arrival, a frag- ment of lobster shell was extracted with a flexible endo- scope by a gastroenterologist. After this procedure, sen- tinel hemorrhage developed. Two hours later, the patient vomited a massive amount of bright red blood and suf- fered shock. Emergency right thoracotomy was per- formed to control the bleeding. An aortic perforating hole 6 mm in diameter was disclosed 2 cm from the origin of the left subclavian artery. The tissues surrounding the fistula were grossly necrotic and friable. When we at- tempted to directly repair the fistula, hemorrhage became massive and uncontrollable. The patient subsequently died of exsanguination.

Patient 2 A 35-year-old housewife was referred from another hos- pital in a state of shock after vomiting a massive amount of bright red blood on March 5, 1990. Eleven days before, she had eaten fish. After this, she experienced fever, dysphagia, substernal pain, and 4-day sentinel hemate- mesis. Endoscopy revealed two esophageal kissing ulcers, resulting from ingestion of fish bone. One ulcer was

Accepted for publication Oct 21, 1991.

Address reprint requests to Dr Wu, Division of Thoracic Surgery, Depart- ment of Surgery, National Cheng-kung University Hospital, No 138, Shen Li Road, Tainan, Taiwan, Republic of China.

cotomy after occlusion of the esophagus and the aorta above and below the fistula. Therefore, we recommend preoperative esophageal tamponade and occlusion of the esophagus and the aorta through a left thoracotomy as the most successful approach.

(Ann Thovac Surg 1992;54:155-6)

located 30 cm away from the incisors. By using a Seng- staken-Blakemore tube and fluid resuscitation, we were able to return the blood pressure to a normal level. An emergency left thoracotomy was performed immediately. The esophagus was first occluded above and below the fistula by encircling tapes. After occlusion of the esopha- gus, the aorta was occluded in the same way (Fig 1). The aortoesophageal fistula was located 6 cm beyond the origin of the left subclavian artery. The closed loop of the esophagus was tensely distended. The distal esophagus was opened first, and some esophageal tissues were left on the aorta. A hole or perforation 6 mm in diameter was found on the medial side of the aorta, which was repaired with 1-0 Prolene suture (Ethicon, Somerville, NJ) and reinforced with a healthy pedicle of esophageal tissues. After this, a gastric tube was pulled up through the hiatus to replace the resected lower half of the esophagus. A subaortic esophagogastrostomy was done. The postoper- ative course indicated positive development, and the patient continued to do well after 1 year of follow-up.

Comment The aortoesophageal fistula induced by foreign bodies is a rare but life-threatening disorder. In patients suffering from dysphagia, chest pain, massive fresh bloody vomit- ing, and a history of problematic ingestion, an aorto- esophageal fistula should be considered. Although Mok and associates [2] reported a case of left subclavian arte- rioesophageal fistula induced by a foreign body in 1989, the aortoesophageal fistula still predominates. The blood vessel most commonly perforated by a foreign body in the esophagus is the aorta 1 to 5 cm from the origin of the left subclavian artery [3]. This is the level of relative narrow- ing of the esophagus, where foreign bodies are more likely to become impacted, and is also the level of closest approximation of the aorta and the esophagus.

In our first case, although an aortoesophageal fistula was entertained preoperatively, the lack of preparation and planning of procedures resulted in the failure of treatment. We subsequently reviewed that case and other cases reported in the literature and concluded that unless the fistula can be controlled before operation and the

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156 CASE REPORT WU AND LA1 AORTOESOPHAGEAL FISTULA

Ann Thorac Surg 1992;54: 155-6

Fig 1. Before division of the aortoesophageal fistula, the esophagus and the aorta were occluded above and below the fistula by encircling tapes.

aortic perforation can be well repaired, success will not be achieved.

To control the exsanguination due to the fistula, a Sengstaken-Blakemore tube is inserted to tamponade the esophagus. This, in addition to the blood transfusion and fluid resuscitation, could maintain signs of life. This procedure also made possible good preoperative prepara- tion and planning. The emergency left thoracotomy pro- vided the best way to occlude the esophagus above and below the fistula by encircling the area with tapes. After occlusion of the esophagus, occlusion of the aorta is performed in the same way. The thoracic aorta can be occluded for 40 minutes, which makes repair of the aortic defect possible. The possibility of damage to the spinal cord, kidneys, or other viscera should be considered in the decision for operation [6]. To reduce ischemic time, we occluded the esophagus first and then the aorta. After these occlusions, the fibrous fistula could be divided and the aorta could be repaired by continuous suture with nonabsorbable, synthetic material. In contrast, with a right thoracotomy, the aorta cannot be conveniently con- trolled and almost always leads to a fatal outcome.

After the aorta has been eroded by a foreign body, even

a small perforation or hole can lead to a massive hemor- rhage. The aortic defect can be directly repaired after debridement of the surrounding friable tissues. In our successful case, one pedicle of healthy esophageal tissue was used to reinforce the aortic primary suture. Ctercteko and Mok [l] did a second operation by resecting a 1-cm disc of the aortic wall to prevent a secondary hemorrhage in their successful case. In 1987, Wilson and co-workers [4] repaired an aortic defect by using a flap of intercostal muscle; the repair was followed by late death on the 29th postoperative day.

The aortoesophageal fistula usually appeared with sur- rounding inflammatory changes. There is no marked suppurative discharge in the mediastinum as reported in the literature. In this condition, after debridement, the gastric tube with omentum may either be able to replace the big esophageal defect or prevent mediastinal infec- tion. A small esophageal defect may occasionally be debrided and closed primarily [I, 41. When the esopha- geal wall is extensively diseased, thoracic esophagectomy with cervical esophagostomy and gastrostomy provides definite control and is the preferred treatment [6]. Conti- nuity of the gastrointestinal tract can be reestablished at a late date.

In summary, the following contribute to minimizing the high mortality of aortoesophageal fistulas: (1) early recog- nition of the ominous signs with a history of problematic ingestion, (2) prompt and effective bleeding control with a Sengstaken-Blakemore tube, (3) occlusion of the esopha- gus and aorta above and below the fistula, (4) direct repair of the aortic defect, including reinforcing with healthy esophageal tissue, through a left thoracotomy.

References 1. Ctercteko G, Mok CK. Aorta-esophageal fistula induced by a

foreign body. The first recorded survival. J Thorac Cardiovasc Surg 1980;80:233-5.

2. Mok CK, Chiu CSW, Cheung HHC. Left subclavian arterio- esophageal fistula induced by a foreign body. Ann Thorac Surg 1989;47:458-60.

3. Sloop RD, Thompson JC. Aorto-esophageal fistula: report of a case and review of literature. Gastroenterology 1967;53: 768-77.

4. Wilson RT, Dean PK, Lewis M. Aortoesophageal fistula due to a foreign body. Gastrointest Endosc 1987;33:448-50.

5. Khawaja FI, Varindani MK. Aortoesophageal fistula. J Clin Gastroenterol 1987;9:3424.

6. Carter R, Mulder GA, Snyder EN Jr, et al. Aortoesophageal fistula. Am J Surg 1978;136:26-30.