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.