MATERIALS AND METHODS
We retrospectively reviewed the clinical charts of six patients who required surgical intervention for the treatment of secondary AEF at Tokyo Medical University Hospital between 2011 and 2016. Primary AEF resulting from esophageal malignancy, thoracic aortic aneurysm, foreign body ingestion, prolonged gastric tube intubation and etc. was excluded. Secondary AEF resulting from esophageal malignancy was not found. Diagnoses were made based on enhanced computed tomography and endoscopic examination. According to the results of blood cultures, antibiotics were initiated based on the recommendations of the infection control team in our institute. This study was conducted in compliance with the Declaration of Helsinki. All patients provided written informed consent for using their clinical data for scientific presentations or publications.
The surgical treatment strategy for each case was designed based on the patient’s frailty and infection severity.1-3 Treatment strategies were considered by a multidisciplinary team that included cardiac and vascular surgeons, general surgeons, radiologists, and anesthesiologists. Optional treatment strategies for AEF included open surgical repair, TEVAR alone, and combined repair with TEVAR and open surgery. In patients with severe infections indicated by air bubbles between the aorta and esophagus on computed tomography (Figure 1a, 1b) or an obvious fistula on endoscopy (Figure 1c, 1d), open surgical repair was considered. In severely deteriorated patients, TEVAR alone was considered. In severely deteriorated patients with severe infection, combined repair with TEVAR as a bridge to open surgery was considered.
Open surgical repair was performed in stages. Following esophagectomy, the proximal stump of the esophagus was pulled out to the left side of the neck and an esophagostomy was performed. Then, reconstruction of the descending aorta using a rifampicin-soaked Dacron graft was performed. After aortic reconstruction, the pleural cavity was left open and copiously irrigated with 12 to 24 liters of 0.2% Gentian violet solution3 per day for about 3 days. After then, omental wrapping around the artificial graft in the left pleural space was performed and the chest was closed. After several months, when the patient’s condition had stabilized, reconstruction of the esophagus using colon interposition was performed through the anterosternal route (Figure 2a). Combined repair was also planned in stages. Following TEVAR to control bleeding due to hematemesis and gain hemodynamic stability, open debridement and reconstruction of esophagus and aorta were planned. In combined repair cases, and cases of TEVAR alone, GORE® TAG® Thoracic Stent Graft (Gore & Associates, Flagstaff, AZ) was chosen as stent-graft because of the durability to infection of expanded polytetrafluoroethylene. Open surgical repair was done by one experienced cardiac surgeon and TEVAR was done by one experienced vascular surgeon.
We assessed clinical outcomes including complications of early and late stages. The early and late mortalities, cause of death, major adverse aortic events and recurrence of infection were also evaluated. Feasibility of the treatment strategy was considered based on these outcomes.