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Successful treatment of an aorto-gastric-bronchial fistula after esophagectomy by placement of double stents
Treatment of an aorto-gastric-bronchial fistula by placement of double stents
Successful treatment of an aorto-gastricbronchial fistula after esophagectomy by placement of double stents Dirk Tuebergen, MD, Stefan Diederich, MD, Sabine Ochmann, MD, Mathias Bruewer, MD, Norbert Senninger, MD, FACS
Anastomotic leakage after esophageal reconstruction has a mortality of 30% on average.1-4 The location of the anastomosis, the onset, and the severity of symptoms further influence the outcome of this complication.5-7 For patients in whom symptoms develop soon after intrathoracic anastomosis, the mortality rate approaches 60%, death usually being caused by mediastinitis and septic complications.8,9 An aorto-gastric fistula is a rare and typically late complication after this type of surgery.10,11 Only 21 cases are reported in English language publications, and in all but one the complication resulted in the death. This is a report of, to our knowledge, the first case of an aorto-gastric-bronchial fistula after esophagectomy that was treated successfully with esophageal and endovascular stents. CASE REPORT A 66-year-old man underwent esophageal resection of a squamous cell carcinoma (pT3 N0 M0) of the distal third of the esophagus. Surgery was performed by means of a right thoracotomy, which extended into the upper abdomen, and an intrathoracic esophagogastrostomy was thus created. Fluoroscopic examination with a water soluble oral contrast medium on the fifth postoperative day Current affiliations: Department of Surgery and Institute of Radiology, University Hospital of Muenster, Wadeyerstr. 1, D48129 Muenster, Germany. Reprint requests: D. Tuebergen, MD, Department of General Surgery, Section of Endoscopy, University Hospital Muenster, Waldeyerstr. 1, D-48129 Muenster, Germany. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/4/128165 doi:10.1067/mge.2002.128165 VOLUME 56, NO. 4, 2002
D Tuebergen, S Diederich, S Ochmann, et al.
revealed free passage of the contrast without extravasation, and enteral nutrition was started. Despite significant risk factors (cardiac insufficiency, atrial fibrillation, atherosclerotic vascular disease, type II diabetes, excessive alcohol use, and previous pancreatitis) the postoperative course was uneventful and the patient was discharged on the postoperative day 14. Eleven days later, sudden massive upper GI bleeding resulted in admission to another hospital. Simultaneous hemoptysis and hypoxemia led to a cardiopulmonary arrest followed by successful resuscitation that included endotracheal intubation. EGD revealed a bleeding, dehiscent anastomosis that was treated by clip application and injection of a solution of epinephrine. As the effects of this procedure would only be short term, the patient was referred again to our institution. EGD immediately after admission to the intensive care unit (ICU) revealed a dehiscence of the anastomosis, which involved one quarter of the circumference, and a fibrin-coated necrotic cavity, but no evidence of bleeding. Bronchoscopy disclosed a 2-mm diameter fistula at the origin of the left main bronchus. Spontaneous arterial bleeding was then encountered, and the endotracheal tube was advanced into the right main bronchus under endoscopic guidance. The cuff was inflated in this location to avoid a spillover of blood to the unaffected side. After the bleeding stopped, the endotracheal tube was replaced with a double lumen tube, sealing the fistula with the cuff of the left portion. This was followed by endoscopic implantation of a 10 cm long, 28 mm maximum diameter, covered expandable metal stent (Ultraflex, Boston Scientific Co., Natick, Mass.) so as to bridge the esophagogastrostomy and seal the leak. On the next day, angiography disclosed a 2 cm pseudoaneurysm of the descending aorta immediately distal to the ligamentum arteriosum (Fig. 1). After surgical exposure of the common femoral artery, a covered endovascular stent graft, 10 cm long and 30 mm in diameter, (Talent stent, Medtronic Co., Minneapolis, Minn.) was implanted. This resulted in complete exclusion of the pseudoaneurysm, as confirmed angiographically (Fig. 2). The patient recovered during 3 weeks in the ICU and 2 further weeks in an intermediate care unit. Treatment included broad-spectrum antibiotics, and no abscess formation was detected on repeated CT. Clinical parameters of GASTROINTESTINAL ENDOSCOPY
587
D Tuebergen, S Diederich, S Ochmann, et al.
Treatment of an aorto-gastric-bronchial fistula by placement of double stents
Figure 1. Radiograph showing inflammatory pseudoaneurysm (arrows) of descending aorta after esophagectomy. Note esophageal stent behind the aorta. infection resolved. Three months after discharge, the esophageal stent was removed endoscopically after bronchoscopy demonstrated closure of the fistula. Enteral nutrition, initially provided by means of a nasojejunal tube, was resumed orally (4 months after primary surgery). Seven months later the patient succumbed to progressive carcinoma without evidence of a new fistula or bleeding.
DISCUSSION Tracheobronchial complications after esophagectomy can occur as a consequence of intraoperative and postoperative trauma, ischemia caused by extensive dissection in the upper mediastinum, and anastomotic leaks with inflammatory involvement of the tracheobronchial tree.12,13 Septic erosion of the aorta in combination with a tracheobronchial fistula is rare and usually fatal.14 The phase of “sentinel bleeding” offers the only chance for therapy, provided the complication is recognized promptly, as in the present case.11 Arterial bleeding into the bronchial tree was found, but the site of bleeding was partially covered by granulation tissue that prevented exsanguination and suffocation. Thus, it became possible to undertake the emergency measures outlined above. Once the patient was stabilized, a decision was needed regarding more definitive therapy. Unfortunately, published case reports provided no generally acceptable guidelines. Several factors were considered: because this was a late complication, severe adhesions were likely to be present and exposure of crucial strictures would be limited at surgery, which would be further compromised by the presence of a necrotic and presumably infected cavity. All of these circumstances were found in a single case report of successful treatment of an aorto-gastric fistula.14 In that patient, 2 operations to reconstruct the 588
GASTROINTESTINAL ENDOSCOPY
Figure 2. Radiograph showing exclusion of pseudoaneurysm after insertion of endovascular stent graft. The angiography catheter is still in place.
aorta ended in formation of a pseudoaneurysm. Ultimately, implantation of an endovascular stent graft led to definitive sealing of the fistula. Therefore, a similar approach was chosen: the endovascular stent sealed the leak in the aorta, thereby preventing exsanguination, and the esophageal stent prevented intestinal secretions from entering the abscess cavity. Moreover, the enteral stent acted as framework to promote closure of the leak without formation of a stenosis. The stent chosen proved to be wide enough (28 mm) to avoid dislodgement and yet was flexible and elastic enough to avoid pressure necrosis and allow subsequent endoscopic removal. Nevertheless, use of a temporary stent to seal an anastomotic leak must be regarded as an experimental procedure, whereas endovascular stent-graft placement has been performed for all types of aortic aneurysm for several years.15,16 Drainage, either surgical or under image guidance, is usually performed before therapy for the type of complication that occurred in our patient. However, multiple CT studies never demonstrated formation of a fluid collection or abscess that required drainage. Enteral nutrition also has a crucial role in the management of postesophagectomy complications17 including preservation of the mucosal barrier and normal immune function.18,19 During the septic phase of the hospital course, however, parenteral nutrition is often the only option. Because of ileus and marked gastric reflux, enteral feeding only became possible at 4 weeks after the onset of the complication in the present case. Although the overall prognosis was poor because of underlying carcinoma, our patient nevertheless survived 7 months after resolution of a complication VOLUME 56, NO. 4, 2002
Esophageal lymphangiomatosis
that is usually fatal. Thus, this case illustrates the value of cooperation among surgeon, endoscopist, radiologist, and anesthesiologist in a seemingly hopeless situation. REFERENCES 1. Bonenkamp JJ, Songun I, Hermans J, Sasako M, Welvaart K, Plukker JT, et al. Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745-8. 2. Boettcher K, Roder JD, Schneider PM, Siewert JR. Risk analysis for surgical therapy for gastric cancer in Germany. Results of the German Gastric Cancer Study 1992. In: Nishi M, Sugano H, Takahashi T, editors. 1st International Gastric Cancer Congress. Bologna: Monduzzi; 1995. p. 55-9. 3. Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomized controlled surgical trial. Lancet 1996;347:995-9. 4. Lam TCF, Fok M, Cheng SWK, Wong J. Anastomotic complications after esophagectomy for cancer. A comparison of neck and chest anastomoses. J Thorac Cardiovasc Surg 1992;104: 395-400. 5. Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after esophagectomy. Br J Surg 1998;85:1146-9. 6. McManus K, Anikin V, McGuigan J. Total thoracic oesophagectomy for oesophageal carcinoma: has it been worth it? Eur J Cardiothorac Surg 1999;16:261-5. 7. Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995;169:634-40. 8. Mueller JM, Erasmi H, Stelzner M, Zieren U, Pichlmaier H.
VOLUME 56, NO. 4, 2002
B-I Lee, B-W Kim, K-M Kim, et al.
9.
10.
11. 12.
13.
14.
15.
16.
17. 18. 19.
Surgical therapy of esophageal carcinoma. Br J Surg 1990; 77:845-57. Patil PK, Patel SG, Mistry RC, Deshpande RK, Desai PB. Cancer of the esophagus: esophagogastric anastomotic leak— a retrospective study of predisposing factors. J Surg Oncol 1992;49:163-7. Couves CM, Howard JM, Amerson JR. Fatal perforation of the thoracic aorta by a gastric ulcer. Am J Surg 1995;95: 878-81. Le Roux BT. Aortic erosion complicating oesophagogastrectomy. Br J Surg 1961;49:271-7. Bartels HE, Stein HJ, Siewert JR. Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome. Br J Surg 1998;85:403-6. Fujita H, Kawahara H, Hidaka M, Nagano T, Yoshimatsu H. An experimental study on viability of the devascularized trachea. Jpn J Surg 1988;18:77-83. Sato O, Miyata T, Matsubara T, Shigematsu H, Yasuhara H, Ishimaro S. Successful surgical treatment of aortogastric fistula after an esophagectomy and subsequent endovascular graft placement: report of a case. Surg Today 1999;29:431-4. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddel RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-34. Fann JI, Miller DC. Endovascular treatment of descending thoracic aortic aneurysms and dissections. Surg Clin North Am 1999;79:551-74. Bengmark S, Gianotti L. Nutritional support to prevent and treat multiple organ failure. World J Surg 1996;20:474-81. Shikora SA, Ogawa AM. Enteral nutrition in the critically ill. Postgrad Med J 1996;72:395-402. Martin KE. The use of early enteral nutrition in abdominal trauma. J Trauma Nurs 1996;3:65-71.
GASTROINTESTINAL ENDOSCOPY
589
Successful treatment of an aorto-gastricbronchial fistula after esophagectomy by placement of double stents Dirk Tuebergen, MD, Stefan Diederich, MD, Sabine Ochmann, MD, Mathias Bruewer, MD, Norbert Senninger, MD, FACS
Anastomotic leakage after esophageal reconstruction has a mortality of 30% on average.1-4 The location of the anastomosis, the onset, and the severity of symptoms further influence the outcome of this complication.5-7 For patients in whom symptoms develop soon after intrathoracic anastomosis, the mortality rate approaches 60%, death usually being caused by mediastinitis and septic complications.8,9 An aorto-gastric fistula is a rare and typically late complication after this type of surgery.10,11 Only 21 cases are reported in English language publications, and in all but one the complication resulted in the death. This is a report of, to our knowledge, the first case of an aorto-gastric-bronchial fistula after esophagectomy that was treated successfully with esophageal and endovascular stents. CASE REPORT A 66-year-old man underwent esophageal resection of a squamous cell carcinoma (pT3 N0 M0) of the distal third of the esophagus. Surgery was performed by means of a right thoracotomy, which extended into the upper abdomen, and an intrathoracic esophagogastrostomy was thus created. Fluoroscopic examination with a water soluble oral contrast medium on the fifth postoperative day Current affiliations: Department of Surgery and Institute of Radiology, University Hospital of Muenster, Wadeyerstr. 1, D48129 Muenster, Germany. Reprint requests: D. Tuebergen, MD, Department of General Surgery, Section of Endoscopy, University Hospital Muenster, Waldeyerstr. 1, D-48129 Muenster, Germany. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/4/128165 doi:10.1067/mge.2002.128165 VOLUME 56, NO. 4, 2002
D Tuebergen, S Diederich, S Ochmann, et al.
revealed free passage of the contrast without extravasation, and enteral nutrition was started. Despite significant risk factors (cardiac insufficiency, atrial fibrillation, atherosclerotic vascular disease, type II diabetes, excessive alcohol use, and previous pancreatitis) the postoperative course was uneventful and the patient was discharged on the postoperative day 14. Eleven days later, sudden massive upper GI bleeding resulted in admission to another hospital. Simultaneous hemoptysis and hypoxemia led to a cardiopulmonary arrest followed by successful resuscitation that included endotracheal intubation. EGD revealed a bleeding, dehiscent anastomosis that was treated by clip application and injection of a solution of epinephrine. As the effects of this procedure would only be short term, the patient was referred again to our institution. EGD immediately after admission to the intensive care unit (ICU) revealed a dehiscence of the anastomosis, which involved one quarter of the circumference, and a fibrin-coated necrotic cavity, but no evidence of bleeding. Bronchoscopy disclosed a 2-mm diameter fistula at the origin of the left main bronchus. Spontaneous arterial bleeding was then encountered, and the endotracheal tube was advanced into the right main bronchus under endoscopic guidance. The cuff was inflated in this location to avoid a spillover of blood to the unaffected side. After the bleeding stopped, the endotracheal tube was replaced with a double lumen tube, sealing the fistula with the cuff of the left portion. This was followed by endoscopic implantation of a 10 cm long, 28 mm maximum diameter, covered expandable metal stent (Ultraflex, Boston Scientific Co., Natick, Mass.) so as to bridge the esophagogastrostomy and seal the leak. On the next day, angiography disclosed a 2 cm pseudoaneurysm of the descending aorta immediately distal to the ligamentum arteriosum (Fig. 1). After surgical exposure of the common femoral artery, a covered endovascular stent graft, 10 cm long and 30 mm in diameter, (Talent stent, Medtronic Co., Minneapolis, Minn.) was implanted. This resulted in complete exclusion of the pseudoaneurysm, as confirmed angiographically (Fig. 2). The patient recovered during 3 weeks in the ICU and 2 further weeks in an intermediate care unit. Treatment included broad-spectrum antibiotics, and no abscess formation was detected on repeated CT. Clinical parameters of GASTROINTESTINAL ENDOSCOPY
587
D Tuebergen, S Diederich, S Ochmann, et al.
Treatment of an aorto-gastric-bronchial fistula by placement of double stents
Figure 1. Radiograph showing inflammatory pseudoaneurysm (arrows) of descending aorta after esophagectomy. Note esophageal stent behind the aorta. infection resolved. Three months after discharge, the esophageal stent was removed endoscopically after bronchoscopy demonstrated closure of the fistula. Enteral nutrition, initially provided by means of a nasojejunal tube, was resumed orally (4 months after primary surgery). Seven months later the patient succumbed to progressive carcinoma without evidence of a new fistula or bleeding.
DISCUSSION Tracheobronchial complications after esophagectomy can occur as a consequence of intraoperative and postoperative trauma, ischemia caused by extensive dissection in the upper mediastinum, and anastomotic leaks with inflammatory involvement of the tracheobronchial tree.12,13 Septic erosion of the aorta in combination with a tracheobronchial fistula is rare and usually fatal.14 The phase of “sentinel bleeding” offers the only chance for therapy, provided the complication is recognized promptly, as in the present case.11 Arterial bleeding into the bronchial tree was found, but the site of bleeding was partially covered by granulation tissue that prevented exsanguination and suffocation. Thus, it became possible to undertake the emergency measures outlined above. Once the patient was stabilized, a decision was needed regarding more definitive therapy. Unfortunately, published case reports provided no generally acceptable guidelines. Several factors were considered: because this was a late complication, severe adhesions were likely to be present and exposure of crucial strictures would be limited at surgery, which would be further compromised by the presence of a necrotic and presumably infected cavity. All of these circumstances were found in a single case report of successful treatment of an aorto-gastric fistula.14 In that patient, 2 operations to reconstruct the 588
GASTROINTESTINAL ENDOSCOPY
Figure 2. Radiograph showing exclusion of pseudoaneurysm after insertion of endovascular stent graft. The angiography catheter is still in place.
aorta ended in formation of a pseudoaneurysm. Ultimately, implantation of an endovascular stent graft led to definitive sealing of the fistula. Therefore, a similar approach was chosen: the endovascular stent sealed the leak in the aorta, thereby preventing exsanguination, and the esophageal stent prevented intestinal secretions from entering the abscess cavity. Moreover, the enteral stent acted as framework to promote closure of the leak without formation of a stenosis. The stent chosen proved to be wide enough (28 mm) to avoid dislodgement and yet was flexible and elastic enough to avoid pressure necrosis and allow subsequent endoscopic removal. Nevertheless, use of a temporary stent to seal an anastomotic leak must be regarded as an experimental procedure, whereas endovascular stent-graft placement has been performed for all types of aortic aneurysm for several years.15,16 Drainage, either surgical or under image guidance, is usually performed before therapy for the type of complication that occurred in our patient. However, multiple CT studies never demonstrated formation of a fluid collection or abscess that required drainage. Enteral nutrition also has a crucial role in the management of postesophagectomy complications17 including preservation of the mucosal barrier and normal immune function.18,19 During the septic phase of the hospital course, however, parenteral nutrition is often the only option. Because of ileus and marked gastric reflux, enteral feeding only became possible at 4 weeks after the onset of the complication in the present case. Although the overall prognosis was poor because of underlying carcinoma, our patient nevertheless survived 7 months after resolution of a complication VOLUME 56, NO. 4, 2002
Esophageal lymphangiomatosis
that is usually fatal. Thus, this case illustrates the value of cooperation among surgeon, endoscopist, radiologist, and anesthesiologist in a seemingly hopeless situation. REFERENCES 1. Bonenkamp JJ, Songun I, Hermans J, Sasako M, Welvaart K, Plukker JT, et al. Randomized comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745-8. 2. Boettcher K, Roder JD, Schneider PM, Siewert JR. Risk analysis for surgical therapy for gastric cancer in Germany. Results of the German Gastric Cancer Study 1992. In: Nishi M, Sugano H, Takahashi T, editors. 1st International Gastric Cancer Congress. Bologna: Monduzzi; 1995. p. 55-9. 3. Cuschieri A, Fayers P, Fielding J, Craven J, Bancewicz J, Joypaul V, et al. Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomized controlled surgical trial. Lancet 1996;347:995-9. 4. Lam TCF, Fok M, Cheng SWK, Wong J. Anastomotic complications after esophagectomy for cancer. A comparison of neck and chest anastomoses. J Thorac Cardiovasc Surg 1992;104: 395-400. 5. Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after esophagectomy. Br J Surg 1998;85:1146-9. 6. McManus K, Anikin V, McGuigan J. Total thoracic oesophagectomy for oesophageal carcinoma: has it been worth it? Eur J Cardiothorac Surg 1999;16:261-5. 7. Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995;169:634-40. 8. Mueller JM, Erasmi H, Stelzner M, Zieren U, Pichlmaier H.
VOLUME 56, NO. 4, 2002
B-I Lee, B-W Kim, K-M Kim, et al.
9.
10.
11. 12.
13.
14.
15.
16.
17. 18. 19.
Surgical therapy of esophageal carcinoma. Br J Surg 1990; 77:845-57. Patil PK, Patel SG, Mistry RC, Deshpande RK, Desai PB. Cancer of the esophagus: esophagogastric anastomotic leak— a retrospective study of predisposing factors. J Surg Oncol 1992;49:163-7. Couves CM, Howard JM, Amerson JR. Fatal perforation of the thoracic aorta by a gastric ulcer. Am J Surg 1995;95: 878-81. Le Roux BT. Aortic erosion complicating oesophagogastrectomy. Br J Surg 1961;49:271-7. Bartels HE, Stein HJ, Siewert JR. Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome. Br J Surg 1998;85:403-6. Fujita H, Kawahara H, Hidaka M, Nagano T, Yoshimatsu H. An experimental study on viability of the devascularized trachea. Jpn J Surg 1988;18:77-83. Sato O, Miyata T, Matsubara T, Shigematsu H, Yasuhara H, Ishimaro S. Successful surgical treatment of aortogastric fistula after an esophagectomy and subsequent endovascular graft placement: report of a case. Surg Today 1999;29:431-4. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddel RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-34. Fann JI, Miller DC. Endovascular treatment of descending thoracic aortic aneurysms and dissections. Surg Clin North Am 1999;79:551-74. Bengmark S, Gianotti L. Nutritional support to prevent and treat multiple organ failure. World J Surg 1996;20:474-81. Shikora SA, Ogawa AM. Enteral nutrition in the critically ill. Postgrad Med J 1996;72:395-402. Martin KE. The use of early enteral nutrition in abdominal trauma. J Trauma Nurs 1996;3:65-71.
GASTROINTESTINAL ENDOSCOPY
589