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© 2003 European Association of Cardio-Thoracic Surgery
Surgery for concomitant aortoesophageal and aortobronchial fistula in tuberculous aortitisDepartment of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, 50, Samdeok 2-ga, Jung-gu, Daegu 700-721, South Korea
* Corresponding author. Tel.: +82-53-420-5675; fax: +82-53-426-4765 Received November 19, 2002; received in revised form January 23, 2003; accepted February 11, 2003
The fistulous formation of tuberculous aortic aneurysm with esophagus and bronchus is very rare and the prognosis is not good. Herein we report a patient who was presented with recurrent hematemesis and hemoptysis and diagnosed as concomitant aortoesophageal and aortobronchial fistula. We carried out left pneumonectomy, aortic graft replacement, and esophageal replacement with stomach simultaneously. Postoperative pathology showed tuberculous aortitis complicated by fistulous formation with esophagus and bronchus. Thirteen months after operation, she is doing well without hematemesis and hemoptysis.
Key Words: Aortic aneurysm; Tuberculosis; Aortoesophageal fistula; Aortobronchial fistula
A 68-year-old lady was transferred to emergency room with recurrent severe hematemesis and hemoptysis. She had a 2-month history of dry cough, weight loss, and chest pain. Laboratory tests showed anemia and decreased number of platelet count. The chest computed tomographic scan demonstrated a ruptured descending thoracic aortic aneurysm. After selective endobronchial intubation with a double-lumen endobronchial tube (DLT), left posterolateral thoracotomy was performed. The left main bronchus near the second carina was severely infected and fistulated, and for this reason, the bronchoplasty was unfeasible. During the surgery, massive hemoptysis through the bronchial lumen of DLT and bleeding from ruptured thoracic aneurysm were developed. Left pneumonectomy was done and the descending thoracic aorta was replaced with 20 mm Hemashield Gold (Meadox Medicals Inc, Oakland, NJ) under the shunt using a 7-mm THI Aortic Perfusion Cannula (Argyle, St. Louis, MO). The esophagoplasty was unfeasible because of an extensive lesion. The gastric mobilization was done through incision of left diaphragm without laparotomy. The esophagectomy was done below carina and esophagogastric anastomosis was performed with Endopath ETS45 Endoscopic Linear Cutter (Ethicon Endo-Surgery, Inc., Cincinnati, OH). The pneumonectomy stump was wrapped with gastric fundus (Fig. 1).
Postoperative radiologic studies revealed that the pneumonectomy space filled with dilated gastric graft without dead space in chest CT scan and the intact esophagogastric anastomosis and good passage in esophagogram (Fig. 2). The pathology of resected specimen revealed a typical tuberculous lesion of aorta, lung, and esophagus. She had taken 6-month anti-tuberculous medication postoperatively. Thirteen months after operation, she is doing well without hematemesis and hemoptysis.
Aortoesophageal or aortobronchial fistula of any cause is uncommon. In the early report, the leading cause of fistula formation was thoracic aortic aneurysm itself [1]. Recently, the surgery of thoracic aorta is considered as common cause of fistula formation. Although there are some reports about the surgery of thoracic aortic aneurysm complicated by aortoesophageal [2] or aortobronchial fistula [3–5], a successful surgical repair of concomitant aortoesophageal and aortobronchial fistula resulting from atherosclerotic aortic aneurysm was reported in the literature [6]. Because of the rare occurrence of fistulous formation, diagnosis requires a high index of suspicion especially in patients without the history of aortic aneurysm, surgery and trauma. Aortography is confirmatory diagnostic modality of aortoesophageal and aortobronchial fistula. Without current bleeding, aortography is negative for fistula. The features of bronchoscopy and esophagoscopy are characteristic, however, these procedures including aortogram precipitate catastrophic hemorrhage [2,3] and should be performed only if immediate thoracotomy is available. Aortobronchial or aortoesophageal fistula is a surgical emergency with a significant risk of secondary infection. When the diagnosis is confirmed, operation should be undertaken immediately. Recently aneurysmectomy and graft replacement is the most popular surgical method of aortic aneurysm. Extraanatomical bypass grafting or the reconstruction with cryopreserved homograft could be an alternative of graft replace to reduce secondary infection. Because primary closure or patch repair has a tendency to postoperative recurrence of fistula [4,5], extensive debridement of aneurysm and adjacent infected tissue is very important and anastomosis should be performed as far from the infected field as possible. One of the esophageal repairs is the primary closure of esophageal perforation, which is frequently unsuccessful due to poor wound strength and poor healing. The wrapping the esophageal closure site with aortic wall, pericardium, pleura, or omental flap is highly recommended for patient of primary esophageal closure. Other techniques are one stage resection followed by gastric pull up and exclusion followed by late reconstruction. In most cases, the left airway is affected because of anatomical relationship. Primary closure or limited lung resection is usually performed, but major pulmonary resection may be necessary [3]. In our case, we performed left pneumonectomy because the inflammation of left main bronchus was severe. To reduce the recurrence of fistulous formation, the wrapping of the aortic repair site with muscle flap or omental flap than with pleural flap. Especially, omentum and muscle flap are also helpful for dead space reduction and prevention of postoperative secondary infection [5,7]. The lifelong antibiotic may be recommended postoperatively [7]. Even though diagnosis is made early, surgical treatment has been largely unsuccessful because of sepsis, hemorrhage or other complications. The determinants of outcome in surgical treatment of infected aortic aneurysm are virulent of the infecting organism and the preoperative state of the infection [8]. Outcome of descending thoracic aortic aneurysm complicated by aortobronchial fistula can be similar to that without fistula, whereas for cases complicated by aortoesophageal fistula the prognosis seems to remain poor even after successful hospital discharge [9], which may related to reduced nutritional status. Recently, surgical outcome depends on the prompt diagnosis and early surgical intervention before massive hemorrhage [2]. doi:10.1016/S1569-9293(03)00039-2
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Abstract
1. Introduction
