Strategies for the treatment of aorto-oesophageal fistula†

OBJECTIVES: Presenting a surgical strategy for aorto-oesophageal fistula (AEF). METHODS: From October 1999 to August 2013, 16 patients with AEF were treated at Kobe University Hospital. The mean age was 65.5 ± 10.2 years, and the male/female ratio was 13/3. Eight patients had non-dissecting thoracic aneurysm, 3 had chronic aortic dissection, 5 had oesophageal cancer and 1 had fish bone penetration. Five patients were in shock. Four patients had previous thoracic endovascular aortic repair (TEVAR) in the descending aorta and 1 had hemi-arch replacement. As treatment for AEF, 8 patients underwent TEVAR, 2 had a bridge TEVAR to open surgery, 2 had extra-anatomical bypass (EAB) and 5 had in situ reconstruction of the descending aorta. The oesophagus was resected in 8 patients, and an omental flap was installed in 7 patients. For the 4 most recent cases, simultaneous resection of the aorta and oesophagus, in situ reconstruction of the descending aorta using rifampicin-soaked Dacron graft and omental flap installation were performed. RESULTS: Hospital mortality was noted in 4 patients (25.0%; persistent sepsis n = 3 and pneumonia n = 1). However, since 2007, only 1 of 5 patients died (pneumonia). All patients with oesophageal cancer died during follow-up. Two patients underwent oesophageal reconstruction using a pedicled colon graft and one is on the waiting list for oesophageal reconstruction. CONCLUSIONS: Bridging TEVAR is a useful adjunct in treating AEF patients with shock. One-stage surgery consisting of resection of the aneurysm and oesophagus, in situ reconstruction of the descending aorta and omental flap installation provided a better outcome in the AEF surgical strategy compared with conservative treatment.