Fístula aorto-esofágica primária: relato de caso / Primary aortoesophageal fistula: case report

Resumo Fístula aorto-esofágica é uma comunicação anormal entre a aorta e o esôfago, causadora de hemorragia digestiva alta potencialmente fatal. O objetivo deste trabalho é relatar um caso de sucesso na abordagem endovascular aórtica única e tratamento conservador do esôfago em fistula aorto-esofágica. A paciente de 81 anos foi admitida com sinais de hemorragia digestiva alta volumosa e, após realização de exames, diagnosticou-se uma fístula aorto-esofágica. Optado pela realização de tratamento endovascular, sendo bem sucedido, a paciente recebeu alta após nove dias de internação e manteve-se em seguimento ambulatorial até a resolução total do quadro. O diagnóstico precoce é extremamente importante, uma vez que se trata de uma patologia fatal na ausência de tratamento. Espera-se agregar conteúdo pertinente para comunidade científica.

Abstract An aortoesophageal fistula is an abnormal communication between the aorta and the esophagus, causing potentially fatal upper gastrointestinal bleeding. The objective of this article is to report a successful case of treatment with a single aortic endovascular approach and conservative treatment of the esophagus in a case of aortoesophageal fistula. An 81-year-old patient was admitted with signs of massive upper gastrointestinal bleeding and, after tests, an aortoesophageal fistula was diagnosed. Endovascular treatment was chosen and performed successfully. The patient was discharged after 9 days in hospital and remained in outpatient follow-up until the condition completely resolved. Early diagnosis is extremely important, since this is a fatal condition if left untreated. It is hoped that this report contributes content of relevance to the scientific community.

Endoluminal Vacuum Therapy (EVAC) in Managing Esophagogastric Anastomosis Fistula / Terapia de vacío endoluminal (Endo-Vac) en el manejo de la fístula de anastomosis esofagogástrica

Abstract Endoluminal vacuum therapy (EVAC) is a promising alternative for the endoscopic management of gastrointestinal fistulas or perforations that do not respond to endoscopic procedures using clips and stents or are even refractory to surgical procedures. In this case report, we describe the successful endoscopic closure of an esophagogastric anastomotic fistula using EVAC, connected to a vacuum system through a probe in the cavity, which did not close with clip management given the friability and edema of the peri-wound tissue. In conclusion, it is a successful alternative to treat these complications, which are sometimes difficult to resolve.

Resumen La terapia de vacío endoluminal (Endo-Vac) es una alternativa promisoria en el manejo endoscópico de las fístulas o perforaciones gastrointestinales, que no responden a procedimientos endoscópicos cuando se utilizan técnicas como clips, stents o incluso refractarias a procedimientos quirúrgicos. En este reporte de caso describimos el cierre endoscópico exitoso de una fístula anastomótica esofagogástrica, utilizando la terapia Endo-Vac, conectada a un sistema de vacío mediante una sonda en la cavidad, que no presentó cierre inicial a manejo con clips, dada la friabilidad y el edema del tejido perilesional. Se concluye que esta es una alternativa exitosa en el cierre de estas complicaciones, que en ocasiones son de difícil resolución.

Research progress of endoscopic vacuum-assisted closure therapy for esophageal fistulas / 中国胸心血管外科临床杂志

@#How to effectively repair esophageal fistulas, caused by esophageal perforation, rupture and anastomotic leakage after esophagectomy has always been a key problem for the digestive surgeon. Although there are many clinical treatment methods, the therapeutic effect is still completely unsatisfactory, especially when severe mediastinal purulent cavity infection is associated with the esophageal fistula. In recent years, foreign centers have promoted a new minimally invasive endoscopic treatment technology to repair the esophageal fistula, endoscopic vacuum-assisted closure therapy, with significantly curative effect. In this article, we will review the specific operation, advantages and disadvantages, as well as the clinical efficacy of endoscopic vacuum-assisted closure therapy in treating the esophageal fistulas, to provide a new therapeutic technique for esophageal fistulas and expand the new field of minimally invasive endoscopic therapy.

H- type tracheoesophageal fistula in a child presenting as recurrent cough

H-type of tracheoesophageal fistula (TEF) is a rare congenital malformation presenting during infancy with choking and recurrent pneumonia. We present a case of H-type TEF with intermittent nonspecific cough, diagnosed on oesophagogastroscopy and upper gastrointestinal contrast study. She was operated at the age of 30 months

Fístula bronquioesofágica asociada a reflujo gastroesofágico / Bronchial-esophageal fistula associated with gastroesophageal reflux

Se presenta un caso clínico demostrativo de fistula broncoesofágica asociado a reflujo gastroesofágico en un varón de 76 años con diagnóstico de reflujo gastroesofágico y hernia hiatal, que acude por episodios de tos de 1 año de evolución sin respuesta a tratamientos. Demostraremos la utilidad del estudio esofagográfico como elemento diagnóstico. Se revisa brevemente los aspectos clínicos, diagnósticos, terapéuticos y probable secuencia de desarrollo de esta complicación.

We present a clinical case of bronchoesophageal fistula associated with gastroesophageal reflux in a 76-year old man with a diagnosis of gastroesophageal reflux and hernia. He comes for episodes of cough of 1 year of evolution without response to treatments. We will demonstrate the usefulness of the esophagographic study as a diagnostic element. The clinical, diagnostic, therapeutic aspects and the probably sequence of development of this complication are briefly reviewed.

Survival outcomes of trachea esophageal fistula in infant

Background: Tracheo-esophageal fistula (TEF) is a rare congenital abnormality often associated with several other anomalies including renal, vertebral column, gastrointestinal or cardiovascular defects. This study was carried out to evaluate the outcome of trachea esophageal fistula among patients who underwent various surgeries for the anastomosis of trachea esophageal fistula.Methods: This study was conducted as a record based cross sectional study among 88 patients who were diagnosed and treated for trachea-esophageal fistula in tertiary care hospital between 2015 and 2018. Data regarding the type of anomaly, presence of associated anomalies, type of surgery and outcomes were documented. Findings of echocardiography and ultrasonography were also documented. Data was analyzed using SPSS software. Chi square test was used to evaluate the outcome of the surgical procedures for management of TEF.Results: Majority of the participants in our study belong to <1 month of age and were males (56.8%). Type 3 tracheo esophageal fistula (80.7%) was the most common type. Associated cardiovascular anomalies were present in 50% of the participants. Thoracotomy with TEF repair was most preferred surgery (76%). Present study demonstrated that surgical techniques improve the physical and physiological outcome of the patients (p <0.05).Conclusions: Trachea esophageal fistula needs to be corrected with surgical procedure. Modern techniques like thorocoscopic anastomosis, thorocosopic techniques to achieve an anastomosis can also be explored. Future studies may be directed in detecting congenital anomalies during the pre-natal period with the help of genetic techniques.

Multiple Embolic Infarcts Caused by Infective Endocarditis Associated with Atrioesophageal Fistula after Percutaneous Radiofrequency Catheter Ablation for Atrial Fibrillation

Infective endocarditis (IE) is not a common cause of stroke. Considering the high mortality rates, however, IE should always be considered as a possible cause of stroke even when the chances are low. Atrioesophageal fistula is a life-threatening condition that can cause IE and subsequent stroke, but the diagnosis is often delayed due to its rarity. We report a case of multiple embolic infarcts caused by infective endocarditis associated with atrioesophageal fistula after radiofrequency catheter ablation for atrial fibrillation.

Successful Open-Surgical Treatment for a Secondary Aorto-esophageal Fistula and Broncho-mediastinal Fistula / 日本心臓血管外科学会雑誌

Patient: A 74-year-old man. Previous history: Total arch replacement for thoracic aortic aneurysm at 72 years old. History of current condition: The patient presented at a local otolaryngology clinic complaining of hoarseness of the voice. Left vocal cord paralysis was present, and as he had previously undergone thoracic vascular graft replacement, he was referred to our department. Further investigation with computed tomography (CT) revealed air in the mediastinum, and he was admitted for treatment of mediastinitis. Post-admission course: Upper gastrointestinal endoscopy revealed esophageal ulceration. After antibiotic treatment, thoracic subtotal esophagectomy via right thoracotomy, esophagostomy, and gastrostomy were performed on admission day 39. Vascular graft infection was also suspected, and antibiotic treatment was therefore continued. As some improvement in inflammatory response was evident, antibiotic treatment was discontinued and the patient's condition was monitored, but fever developed on day 107, and CT again revealed air in the mediastinum. Bronchoscopy revealed a broncho-mediastinal fistula in the left main bronchus. On day 110, repeated total arch replacement using a vascular graft, omentoplasty, and left main bronchus repair were performed via left thoracotomy. Esophageal reconstruction was left for later surgery, but follow-up CT on day 160 again revealed air in the mediastinum. Bronchoscopy was performed the same day and revealed a broncho-mediastinal fistula in the left main bronchus, located on distally from the previous fistula. This fistula was surgically closed on day 173. The subsequent course was favorable, and antethoracic esophageal reconstruction by jejunal elevation was performed on day 233. The patient was able to start eating on day 244, and was discharged in an improved condition on day 250.

Esophago-Mediastinal Fistula Due to Tuberculous Mediastinal Lymphadenitis / 대한내과학회지

Tuberculosis rarely involves the esophagus, and most esophageal tuberculosis occurs secondary to adjacent tuberculous lymphadenitis. An esophago-mediastinal fistula is a very unusual complication of tuberculous lymphadenitis. Herein, we report a case of an esophago-mediastinal fistula due to tuberculous lymphadenitis. A 28-year-old woman who had dysphagia was assessed by chest computed tomography, endoscopy, esophagogram, and a lymph node biopsy. An esophago-mediastinal fistula was found and an antituberculous agent was considered initially. However, because of her severe dysphagia, she managed with endoscopic clipping as an alternative. However, the fistula remained on follow-up esophagography. A gastrostomy was eventually performed, and she was treated with an antituberculous agent. The fistula had closed after 4 weeks of medication. Antituberculous agents are the mainstay treatment for esophago-mediastinal fistula due to tuberculous lymphadenitis; endoscopic clipping may be a complementary treatment.

Fístula esofágica por adenitis mediastinal tuberculosa / Esofagic fistula by mediastinal tuberculosa adenitis

Se presenta una fístula esofágica por adenitis mediastinal tuberculosa, que evoluciónó favorablemente con tratamiento antituberculoso. Se hacen consideraciones acerca de la escasa frecuencia de estos casos, su confusión con otras enfermedades y su buena evolución con tratamiento médico.

A case of oesophageal fistulae caused by tuberculous mediastinal adenitis, which evolved favorably with antituberculous treatment is presented. Considerations about the rarity of these cases, confusion with other diseases and their good performance with medical treatment are made.

Fístula esofágica por tuberculosis en pacientes con VIH: Presentación de dos casos / Tuberculosis Esophageal Fistula in HIV Patients: Report of Two Cases

En los pacientes con VIH es frecuente la tuberculosis (TB) extrapulmonar; sin embargo, la incidencia de afectación esofágica es baja. Se requiere de una alta sospecha clínica para realizar un adecuado enfoque diagnóstico y para identificar al Mycobacterium TB como agente causal de infección. Los estudios por imagen, como la radiografía convencional de tórax, el esófagograma, la tomografía computarizada multicorte (TCM) y la endoscopia digestiva superior aportan información basada en hallazgos específicos que pueden orientar hacia el diagnóstico de TB ganglionar y esofágica. Sirven como guía para la toma de muestras de tejidos y la realización de estudios confirmatorios de presencia del bacilo, como las pruebas moleculares y cultivos. Se reseñan 2 casos de pacientes jóvenes, de sexo masculino, con diagnóstico de VIH/sida C3 con coinfección por TB, quienes desarrollaron compromiso ganglionar mediastinal y esofágico, con perforación secundaria y fístula mediastínica.

Extrapulmonary tuberculosis (TB) is frequent in HIV patients; nevertheless, the incidence of esophageal involvement is low and high clinical suspicion is required for a proper diagnostic approach in order to identify Mycobacterium TB as a causative agent of infection. Imaging studies such as conventional chest radiography, esophagogram, multislice computed tomography (MCT), and upper endoscopy provide information based on specific findings that can lead to the diagnosis of TB. They serve as a guide for tissue sampling and confirmatory molecular tests and cultures. This article presents two cases of young male patients diagnosed with HIV/AIDS C3 and co-infected with TB, who developed esophageal and mediastinal lymph node involvement, with secondary perforation and mediastinal fistula.

Emergency treatment for aorto-esophageal fistula by endovascular aortic repair / 中华胸心血管外科杂志

Objective To investigate the clinical features,essentials of diagnosis,selection of endovascular treatment and prognosis of aorto-esophageal fistula(AEF).To improve the understanding of the disease.Methods 3 patients with AEF from October 2010 to July 2016 in Changhai Hospital,including clinical symptoms and signs,endovascular treatment process and follow-up results,and review the relevant literature.Results Two of the 3 patients are men,and another is a woman.Aged 64-70 years.The causes of AEF are chest trauma,thoracic aorta pseudoaneurysms and foreign body ingestion,respectively.All the 3 patients had chest pain,hematemesis,and fever.Two of them showed sentinel hemorrhage and another showed a sudden massive hematemesis.Upper gastrointestinal endoscopy or computed tomographic angiography (CTA) confirmed the diagnosis in all patients.They all underwent thoracic endovascular aortic repair(TEVAR).The effect was good in acute phase.It didn't have any significant short-term complications.Re-bleeding time was 35 days to 85 days.Two patients died of recurrent severe hemorrhage post operation,and one of them had received TEVAR again but not it was ineffective.Another died of multiple organ failure after open surgery.Conclusion Since it showed the short-term effect but not the long-term effect,TEVAR can only be applied as a temporary remedy to the patients in poor conditions and be substituted by the open surgery when the patients were in better conditions.

Mediastinal pancreatic pseudocyst naturally drained by esophageal fistula / 영남의대학술지

Mediastinal pancreatic pseudocyst is a rare complication of acute or chronic pancreatitis. Pleural effusion and pneumonia are two of the most common thoracic complications from pancreatic disease, while pancreaticopleural fistula with massive pleural effusion and extension of pseudocyst into the mediastinum is a rare complication of the thorax from pancreatic disease. To the best of our knowledge, there have been no case reports of mediastinal pancreatic pseudocyst-induced esophageal fistula in Korea to date. Here in, we report a case about 43-year-old man of mediastinal pancreatic pseudocyst-induced esophageal fistula presenting with chest pain radiating toward the back and progressive dysphagia. The diagnosis was confirmed by an esophagogastroduodenoscopy and abdomen computed tomography (CT). The patient was treated immediately using a conservative method; subsequently, within 3 days from treatment initiation, symptoms-chest pain and dysphagia-disappeared. In a follow-up gastroscopy 7 days later and abdomen CT 12 days later, mediastinal pancreatic pseudocyst showed signs of improvement, and esophageal fistula disappeared without any complications.

A Case of Delayed Tracheo-esophageal Fistula Complicating Acute Intoxication of Hydrogen Peroxide

Hydrogen peroxide is a commonly used oxidizing agent. If injected, it may result in morbidity via direct caustic injury, oxygen gas formation, and lipid peroxidation. We report a 40-year-old male patient who accidentally swallowed undiluted hydrogen peroxide (35%). The initial chest computed tomography scan showed no active lesions. He was admitted to the intensive care unit for conservative treatment. Fourteen days after treatment, uncontrolled fever and foul oder sputum occurred, which was not alleviated despite empirical antibiotics therapy. Findings on a chest computed tomography showed tracheo-esophageal fistula at the lower trachea and left main bronchus. He underwent surgical replacement surgery and was discharged without complication after 52 days of admission.

Primary Aortoesophageal Fistula Presented as Massive Upper Gastrointestinal Bleeding

An aortoesophageal fistula is one of the very few causes of upper gastrointestinal bleeding but can be fatal if the diagnosis is delayed. This usually occurs secondary to esophageal or aortic surgery. A primary aortoesophageal fistula is rare and less likely to be suspected. Here, we present a case of a primary aortoesophageal fistula that presented as massive upper gastrointestinal bleeding. An 81-year-old man with a history of aortic aneurysm had syncope and bright color hematemesis. The aortoesophageal fistula was not diagnosed early enough and the patient died. Therefore, emergency physicians should consider aortoesophageal fistula as a potential cause when encountering upper gastrointestinal bleeding.

Mediastinal pancreatic pseudocyst naturally drained by esophageal fistula / 영남의대학술지

Mediastinal pancreatic pseudocyst is a rare complication of acute or chronic pancreatitis. Pleural effusion and pneumonia are two of the most common thoracic complications from pancreatic disease, while pancreaticopleural fistula with massive pleural effusion and extension of pseudocyst into the mediastinum is a rare complication of the thorax from pancreatic disease. To the best of our knowledge, there have been no case reports of mediastinal pancreatic pseudocyst-induced esophageal fistula in Korea to date. Here in, we report a case about 43-year-old man of mediastinal pancreatic pseudocyst-induced esophageal fistula presenting with chest pain radiating toward the back and progressive dysphagia. The diagnosis was confirmed by an esophagogastroduodenoscopy and abdomen computed tomography (CT). The patient was treated immediately using a conservative method; subsequently, within 3 days from treatment initiation, symptoms-chest pain and dysphagia-disappeared. In a follow-up gastroscopy 7 days later and abdomen CT 12 days later, mediastinal pancreatic pseudocyst showed signs of improvement, and esophageal fistula disappeared without any complications.

Case-control study on related risk factors of aortic-esophageal fistula after esophageal carcinoma operation / 重庆医学

Objective To explore the related risk factors of aortic esophageal fistula (AEF) after esophageal carcinoma operation.Methods According to the design of case-control study and matching proportion of 1:3,18 cases of AEF after esophageal carcinoma operation treated in the thoracic surgery department of Daping Hospital of Third Military Medical University from 2000 to 2015 served as the observation group,and contemporaneous 54 cases of esophageal carcinoma operation,who had approximate basic diseases or risk factors,were selected as the control group,18 pairs were formed.The risk factors possessed by the observation group before disease onset such as age,sex,tumor TNM stage and tumor location served as the matching variables.The non-matching variables including operation time,preoperative body mass index (BMI),amount of intraoperative hemorrhage,preoperative LDL level,anastomosis mode,postoperative pulmonary complications,postoperative arrhythmia,preoperative hypertension,preoperative diabetes and number of removed lymph nodes were performed the case-control study.Results The univariate Logistic analysis preliminarily screened out 5 risk factors,including preoperative obesity,preoperative LDL level,postoperative pulmonary complications,anstomosis mode and number of removed lymph nodes,the difference in other factors was not statistically significant (P＞ 0.05).The multivariate non-conditional Logistic stepwise regression analysis revealed that preoperative obesity (OR =8.63,95 ％ CI=1.35-17.60),preoperative LDL level (OR =0.81,95 ％ CI =0.23-0.98) and the number of intraoperatively removed lymph nodes (OR =0.32,95 ％ CI =0.14-0.59) had statistical differences between the observation group and control group,but the difference in other factors had no statistical significance.Conclusion Preoperative obesity,preoperative LDL level and number of removed lymph nodes might be the risk factors for AEF occurrence after esophageal carcinoma operation.

Clinical analysis of risk factors for postoperative anastomotic leakage in geriatric patients with esophageal carcinoma / 中华老年医学杂志

Objective To investigate the risk factors for postoperative anastomotic leakage in geriatric patients with esophageal carcinoma and provide new insights into clinical prevention and treatment.Method The fifty-six patients with anastomotic fistula were chosen from 636 esophageal carcinoma patients who underwent esophagectomy in Department of Thoracic Surgery from January 2011 to January 2016.In the 56 patients,the ratio of male (39 cases) to female (17 cases) was 2.3 ∶ 1.0,with the age range of 60-81 years,average of (66.4±8.6) years.The retrospective analysis was performed for obtaining the risk factors for anastomotic leakage.Results Fifty six cases who suffered from anastomotic fistula showed 10 cases (17.9％)with hormone administration,17 cases (30.4％) with preoperative chemo-radiotherapy,32 cases (57.1％) with the basic diseases,27 (48.2％) with preoperative dystrophia.In addition to the old age and tumor,the other risk factors for anastomotic leakage included the hormone use,preoperative malnutrition,and preoperative chemoradiotherapy.Conclusion High attentions have to be paid to the prevention and treatment of anastomotic fistula patients with chronic diseases,hormone use,preoperative malnutrition and preoperative chemo-radiotherapy.

Diagnosis and treatment of pharyngostoma and esophagostoma after anterior cervical spine surgery / 中华骨科杂志

Objective To investigate the diagnosis,treatment and prevention strategies of pharyngostoma and esophagostoma caused by anterior cervical spine surgery.Methods A retrospective analysis were performed in 17 cases of anterior cervical operation complicated with pharyngeal and esophageal fistula from 1999 March to 2010 June,including 11 male cases and 6 female cases,aged from 7 to 67 years with the mean age of 44.23 years.16 cases (94％) got inflammation of anterior cervical surgery incision and throat pain.2 cases (11％) accompanied by high fever,whose body temperature was as high as 39.2° and incision particles or liquid flew after eating.17 cases underwent upper gastrointestinal radiography,and regular oral methylene blue.Barium overflew from fistula in 2 cases (11％) after upper gastrointestinal tract barium meal angiography,while methylene blue overflew from incision in 7 cases (41％) after oral methylene blue.Through X-ray examination,gas fistula before vertebral was visible in 14 cases (82％).A diagnosis can be made by outflow through fistula after barium esophagography or oral administration of methylene blue.For unknown but highly suspected pharyngeal and esophageal injury,operation can be confirmed if no improvement of symptoms was found after fasting,nasogastric or parenteral nutrition,and ant-infection treatment for 1 week.Results All of 17 patients underwent surgical treatment.During operation,fistula dot or small irregular shape can be seen in 8 cases;long stripe in 3 cases;boundary not clear or irregular in 2 cases;adhesion around the fistula of anterior cervical fascia,similar to tear in 1 case;two fistula in 1 case;fistula located in pharynx posterior wall or esophageal which was not clear or fistula of unknown reason in 2 cases (fascia might be not at the same side of incision or fascia was small and already closed).Pharynx posterior wall and esophageal fistula was found in 3 cases during surgical exploration,which was immediate sutured and placed with drainage tube.After 7 to 14 days,if flow was less than 30 ml,and no bacterial growth was found in 3 consecutive drainage fluids,we pull out the tube.Patients who underwent nasal feeding for 2 to 3 weeks,and then took liquid diets complained nothing,and cured after 1 month.12 cases underwent debridement,stitching fistula,irrigation and drainage tube placement instantly.The wash pipe was removed after 12 to 21 days and 3 consecutive drainage fluids showed no bacterial growth.Then 2 to 3 days later the drainage pipe was pull out.Two to three months later these patients healed.2 cases firstly underwent debridement and suture or part suture,and then the incision was opened and filled with nitrofurazonium gauze tamponade.Gradually pull out the filling gauze and change the dressing of wound.If the residual cavity was large or the drainage was pus,flush the wound with physiological saline once a day,then three times a week,and finally once a week.These patients healed after 6 to 12 months.Pharyngostoma or esophagostoma of all patients was found timely,and active surgical treatment was performed,so no obvious complications was found postoperatively.All 17 patients recovered and resumed diet after 1 to 12 months postoperatively.Conclusion Pharyngeal and esophageal fistula is a rare but severe complication after anterior cervical surgery,which seriously affect the effect of operation and even lead to death.Early diagnosis and active intervention can obtain satisfactory curative effect.

Endoscopic management of postsurgical leaks

Postsurgical leaks are a major complication with significant mobidity and mortality. Conventional conservative and surgical approaches are highly morbid with limited success. Over the last decade several endoscopic techniques have proved effective with a favorable safety profile. Nevertheless, most data still come from retrospective series, and many studies included heterogenous patient groups pooling complex surgical leaks with minor endoscopic perforations. This review focuses on the endoscopic management of the more difficult postsurgical leaks. Stents and over-the-scope clips are currently the key endoscopic techniques for leak closure, but emerging techniques such as vacuum sponge therapy and endoscopic internal drainage have proved to be at least as effective. The current trend is to use these different techniques interchangeably or simultaneously rather than assuming a single standardized approach.