431O. Sato et al.: Aortogastric Fistula After EsophagectomySurg TodayJpn J Surg (1999) 29:431–434

Abstract: An aortogastric fistula is a rare but fatal complica-tion after an esophagectomy and intrathoracic esophagogas-tric anastomosis. A 54-year-old man underwent an esophagealresection due to carcinoma in his lower esophagus. Thealimentary tract continuity was restored by intrathoracicesophagogastric anastomosis. Forty-six days later, he suffereda massive hematemesis due to an aortogastric fistula whichhad formed at the esophagogastric suture line. The fistula wassurgically obliterated twice, but each operation was followedby pseudoaneurysm formation. The patient was finally suc-cessfully treated with an endovascular stent graft placement.This is the first report of a patient surviving after developingthis complication.

Key Words: aortogastric fistula, esophagectomy, esophagealcancer, aortoenteric fistula, endovascular graft

Introduction

An aortogastric fistula is a rare but fatal complicationafter an esophagectomy and intrathoracic esophagogas-tric anastomosis, and no survivors have previously beenreported. We herein present the first successful surgicaltreatment and endovascular stent graft placement insuch a case.

Case Report

A 54-year-old man underwent a lower esophageal re-section to remove an advanced squamous cell carci-noma from the lower third of his esophagus on May 15,1996. The operation was undertaken via a left

thoracotomy in the sixth intercostal space which ex-tended into the upper abdomen, and an intrathoracicesophagogastrostomy was thus created. A postopera-tive contrast study of the esophagogastric anastomosisperformed on May 24 suggested minor leakage, andtherefore a computed tomography (CT) scan was per-formed on May 27, which also revealed a small air spacebeside the suture line. A repeat CT examination onJune 13 again showed an air space adjacent to the aorta(Fig. 1), and thus oral feeding was delayed until June 24.There was no fever nor leukocytosis.

On the morning of July 1, 1996, 46 days after theoperation, the patient suddenly vomited about 2000 mlof blood and fell into shock. We diagnosed anaortogastric fistula and rushed him to the operatingroom. After creating a right axilloexternal iliac arterybypass, we made a posterolateral thoracotomy in thefifth intercostal space. The adhesion was lysed with dif-ficulty. A 2-mm fistula between the descending aortaand the esophagogastric suture line was confirmed.The esophagus and clot-filled stomach were transectedabove and below the anastomotic line, and the aortawas clamped. The anastomotic portion was removedand the contaminated aortic wall was debrided aroundthe fistula. The perforation of the aorta was directlyclosed with pledgeted 2-0 polypropylene sutures. Theremaining esophagus was freed and a cervicalesophagostomy was created. Next, the operative fieldwas thoroughly irrigated before of the chest was closed.The axilloiliac bypass graft was then removed. Theoperative blood loss was 3 016g.

Thereafter, antibiotic treatment was started and thepatient was closely followed with weekly CT scans. ByJuly 20, 1996, we noticed a gradual bulging of the aorticwall at the suture-closed site. Angiography on July 23confirmed the presence of a 1-cm pseudoaneurysm. Athird operation was done on July 24, 1996, 70 days afterthe first operation. Initially the left external iliac arterywas harvested and replaced with a Dacron graft. A tem-

Case Reports

Successful Surgical Treatment of Aortogastric Fistula Afteran Esophagectomy and Subsequent Endovascular Graft Placement:Report of a Case

Osamu Sato1, Tetsuro Miyata2, Toshiki Matsubara3, Hiroshi Shigematsu2, Hiroshi Yasuhara2,and Shin Ishimaru4

1 Department of Surgery, Saitama Medical Center, 1981 Tsujido Kamoda, Kawagoe, Saitama 350-8550, Japan2 Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan3 Department of Surgery, Cancer Institute Hospital, Tokyo, Japan4 Second Department of Surgery, Tokyo Medical College, Tokyo, Japan

Reprint requests to: O. Sato(Received for publication on Dec. 17, 1997; accepted on Sept.11, 1998)

432 O. Sato et al.: Aortogastric Fistula After Esophagectomy

closed with an iliac artery patch that had been harvestedat the beginning of the operation. The operating timewas 12 h and the blood loss amounted to 10000 g.

At the end of September, a CT examination againrevealed a pseudoaneurysm at the same site.Angiography performed on September 30 confirmedthe recurrence of a 17 3 12-mm aneurysm (Fig. 2A).The leukocyte counts were within the normal limits andC-reactive protein was 1.1 to 1.5 mg/dl. Encouragedby the sterility of the granulation tissue procuredduring the previous operation, we decided to performendovascular grafting on October 7, 1996. A thin-walled30-mm woven Dacron graft was secured around twotandemly arranged self-expandable stents. An 8-mmDacron graft was sutured to the right common iliacartery. Next, the right brachial artery was punctured,and a guide wire was passed from the brachial artery tothe iliac graft. While the guide wire was held tight, anintroducer was advanced over the guide wire from be-low and the stent graft was then placed in the descend-ing aorta under pharmacologically induced hypotension(Fig. 3). An intraoperative angiogram showed an imme-diate obliteration of the aneurysm (Fig. 2B). The post-operative course was uneventful.

The alimentary tract was later reconstructed with ajejunal segment brought up to the neck through a sub-cutaneous tunnel in the Roux-Y fashion on November8, 1996. At present the patient is alive and well 19months after the esophagectomy.

Fig. 2. A Angiogram made immedi-ately before the placement of thestent graft shows a pseudoaneurysmin the descending aorta (arrow). BAngiogram made immediately afterthe placement of the stent graftshows the pseudoaneurysm to havebeen successfully obliterated

porary bypass was made between the right axillary ar-tery and the Dacron graft. The patient was placed in theright lateral position and the thoracic cavity was en-tered. The pseudoaneurysm was now approached witheven greater difficulty. The granulation tissue aroundthe pseudoaneurysm was removed and sent for bacte-riological examination, and was later proved to be ster-ile. Due to the danger of placing prosthetic material in apotentially infected field, the opening in the aorta was

Fig. 1. Small air space adjacent to the aorta (arrow), whichsuggests minor leakage

433O. Sato et al.: Aortogastric Fistula After Esophagectomy

esophagectomy. There have been 20 cases reported inthe English literature which followed intrathoracicesophagogastric anastomosis,1–10 and all reportedpatients died (Table 1). Of the 21 cases including

Table 1. Reported cases of aortoesophagogastric fistula after esophageal resection

Time fromesophagealresection to Time from initial Location/

First authorRef. bleeding bleeding to death etiology

Maguire1 40 days 3h Anastomotic lineMerendino2 12 days 1.5h Anastomotic line

80 days 1 day Anastomotic lineBrookes3 56 days Soon Gastric ulcerCouves4 7 years Soon Gastric ulcerLe Roux5 28 days l day Anastomotic line

15 days 5h Anastomotic line14 days 8h Anastomotic line37 days 3 days Anastomotic line14 days 5h Anastomotic line19 days 30h Anastomotic line27 days Soon Anastomotic line11 days 8h Anastomotic line13 days 30min Anastomotic line31 days 3 days Anastomotic line

Ullmann6 5 weeks 1 day Esophageal ulcerDeutsch7 5 weeks 1 day Gastric ulcerLau8 3 weeks Soon Gastric ulcerRasuli9 14 months 6h Gastric ulcerBegin10 14 days 2h Gastric ulcerPresent case 46 days — Anastomotic line

Discussion

Although there may well be many unreported fatalities,an aortogastric fistula is a rare complication following an

Fig. 3. Schematic representation ofthe endovascular stent graft deploy-ment used in this case

434 O. Sato et al.: Aortogastric Fistula After Esophagectomy

the present one, anastomotic leakage accounts for 14 ofthe fistulas,1,2,5 and a peptic ulceration in the stomach oresophagus was responsible for the other seven.3,4,7–10 Theinterval between the esophagectomy and the hemate-mesis varied from 11 days in a leakage case5 to 7 years ina gastric ulcer case.4 Death ensued within 6 h after theinitial bleeding in 12 cases and within 1 day in the remain-ing six. Therefore, immediate intervention is the onlyway to save the patient. If the aorta cannot be imme-diately accessed, the esophagus and stomach should betransected first in order to tamponade the bleeding.

To avoid placing prosthetic material in an infectedfield, we tried to directly close off the perforation and, inthe third operation, use an iliac artery patch closure;however, both did not last long. Although no overt signof infection was present in the interim, a low-gradeinfection may have contributed to the failure of thedirect closure. Granulation tissue obtained at the timeof the patch closure grew no organisms, thus the failureof the patch may have been due to the mechanicalweakness of the iliac artery wall. Nevertheless, precioustime was gained by these operations to sterilize theoperative field, thus allowing for the later endovasculartreatment. Endovascular grafting could not have beenused as the primary treatment of this condition, becausecontinual bacterial contamination from the alimentarytract would have inevitably led to graft sepsis.

Repeat CT examinations are invaluable as follow-upmeasures. Regarding pseudoaneurysm recurrence, anendovascular stent graft placement is also a usefulbackup modality providing that sterilization has beenachieved.

Prevention is of course more desirable than emer-gency surgery for this highly lethal condition. An ampleamount of omentum should be interposed between thealimentary tract and the aorta whenever an intratho-racic esophagogastrostomy is performed.

References

1. Maguire WC, Mitchell N (1947) Perforation of the aorta by acidgastric contents at site of gastroesophagostomy. Surgery 22:842–844

2. Merendino KA, Emersson EC (1950) Aortoesophagogas-tric fistula, an unusual complication of esophagogastrostomyperformed under the aortic arch following esophageal resec-tion for carcinoma. A report of two cases. J Thorac Surg 19:405–411

3. Brookes VS, Stafford JL (1952) Peptic ulceration and perforationof the stomach after oesophagectomy. Thorax 7:167–169

4. Couves CM, Howard JM, Amerson JR (1958) Fatal peforation ofthe thoracic aorta by a gastric ulcer. Am J Surg 95:878–881

5. Le Roux BT (1961) Aortic erosion complicating oesophago-gastrectomy. Br J Surg 49:271–277

6. Ullmann AS, Shier KJ, Horn RC (1961) Aortoesophageal fistula:an unusual complication of esophago-gastrostomy, following re-section for carcinoma of the esophagus. Can Med Assoc J 85:27–31

7. Deutsch AA, Reiss R (1978) Aortogastric fistula: an unusual com-plication of the thoracic portion of the stomach. Arch Surg113:537

8. Lau OJ (1983) Acute aortogastric fistula following gastro-esophageal anastomosis. Br J Surg 70:504

9. Rasuli P, Hammond DI, Eidus LB, Pattee PL (1990) Peptic ulcer-induced gastroaortic fistula: difficulty in making the diagnosis withselective angiography. J Can Assoc Radiol 41:151–152

10. Begin LR, Sheiner NM (1992) Anastomotic ulcer-inducedaortoenteric fistula after esophagogastroplasty. Ann Thorac Surg54:564–565