Interact CardioVasc Thorac Surg 2008;7:322-324. doi:10.1510/icvts.2007.164699
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Vascular thoracic |
Successful one-stage operation of aortoesophageal fistula from thoracic aneurysm using a rifampicin-soaked synthetic graft
Takehiro Inouea,*,
Takako Nishinoa,
Ying-Feng Pengb and
Toshihiko Sagaa
a Department of Cardiovascular Surgery, Kinki University School of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan
b Department of Surgery, Kinki University School of Medicine, Osaka, Japan
Received 7 August 2007;
received in revised form 23 September 2007;
accepted 25 September 2007
*Corresponding author. Tel.: +81-723-66-0221; fax: +81-723-67-8657.
E-mail address: rtcryo{at}hotmail.co.jp (T. Inoue).
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Abstract
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Aortoesophageal fistula secondary to thoracic aneurysm is rare, but is usually lethal, and few survivors have been reported. We report successful surgery for aortoesophageal fistula in a one-stage operation. Repair involved in situ replacement of the thoracic aneurysm using a rifampicin-soaked graft, primary repair of the esophagus, omental wrap and tube jejunostomy. This is the original report of the surgical repair of aortoesophageal fistula using a rifampicin-soaked graft.
Key Words: Aortoesophageal fistula; Thoracic aneurysm; Rifampicin; Omental wrap
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1. Introduction
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Aortoesophageal fistula (AEF) secondary to a thoracic aortic aneurysm is one of the most challenging entities faced by cardiothoracic surgeons. The risk of operation for AEF is even higher because of emergency conditions associated with gastrointestinal bleeding, redo operation, and possible infection of the aortic lesion [1]. Despite various surgical interventions for AEF, few survivors have been reported. We report herein successful one-stage repair of AEF using a rifampicin-soaked graft and omental wrap.
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2. Case presentation
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The patient was a 51-year-old woman who was admitted to Kinki University Medical Hospital with hematemesis requiring transfusion of four units of packed red blood cells. She had a 3-week history of midthoracic pain prior to admission. Eleven years prior to this admission, descending aortic dissection (Stanford type B) had been repaired using a Dacron graft. She received long-term medication for persistent hypertension postoperatively. Upper endoscopy during hospitalization demonstrated an extrinsic mass compressing the midesophagus with overlying clot (Fig. 1a). Computed tomography showed a thoracic aortic aneurysm (diameter, 6 cm; length, 5 cm) with thrombus just distal of the previous graft, in close contact with the esophagus (Fig. 1b).
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Fig. 1. (a) Preoperative upper endoscopic view showing an extrinsic mass compressing the midesophagus (black arrow). (b) Preoperative computed tomography of the chest showing thoracic aortic aneurysm with thrombus just distal to the previous graft, in close contact with the esophagus. (c) Postoperative computed tomography six months after AEF repair showed omental tissue tightly surrounding the rifampicin-soaked graft.
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Under a diagnosis of AEF from the thoracic aneurysm, surgery was performed immediately. After induction of general anesthesia, spinal drainage and left posterior lateral thoracotomy were performed. Cardiopulmonary bypass was instituted with cannulation to the right femoral vessels at mild hypothermia. When the aneurysm was opened, a 1.5-cm aortic fistula to the esophagus was apparent near-by the distal anastomosis of the previous Dacron graft. The descending thoracic aneurysm was replaced with a 26-mm Dacron graft (Hemashield graft; Boston Scientific, Boston, MA). That graft was soaked in rifampicin for 20 min prior to replacement, to prevent infection. The esophageal fistula was firmly attached to the aneurysmal wall with no findings of purulence. Therefore, the esophageal opening was carefully identified and debrided, then repaired directly (Fig. 2). Additionally, the esophageal repair was bolstered and reinforced with the aneurysmal wall. The cultures of the aneurysmal wall and the thrombus were negative. Upper laparotomy was subsequently performed and an omental pedicled flap was constructed. The in situ rifampicin-soaked graft was wrapped with the omental flap, and the closure site of AEF was covered fully with omental tissue. In addition, a tube jejunostomy was placed for postoperative transenteral nutrition.
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Fig. 2. Intraoperative image showing the descending thoracic aortic graft (black arrow) and the primary repair of the aortoesophageal fistula (white arrow). The Dacron graft was soaked in rifampicin for 20 min prior to replacement.
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Enteral nutrition was started through the tube jejunostomy from eight days postoperatively. The patient received intravenous antibiotic therapy for three weeks until inflammation findings were negative. Afterwards, the patient tolerated a regular diet without swallowing difficulties, and tube jejunostomy was removed three months after AEF repair. Postoperative computed tomography six months after AEF repair showed omental tissue tightly surrounding the rifampicin-soaked graft (Fig. 1c). As of the time of writing, after 15 months of follow-up, the patient is treated with oral intake of suppressive antibiotics currently, and is doing well without esophageal leak or graft infection.
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3. Comments
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Traditional treatment of aortoenteric fistula with aneurysm has consisted of aneurysm excision, extra-anatomical bypass, and reconstruction of the alimentary tract [2]. Some authors have recently recommended in situ replacement for aneurysm with aortoenteric fistula [3, 4]. A variety of conduits for in situ replacement have been used, including autologous vein, polytetrafluoroethylene graft, cryopreserved homograft, and antibiotic-bonded graft [5]. Cryopreserved homograft seems preferable for in situ replacement in such patients, but is not readily available. More recently, silver-coated grafts have become available. The antimicrobial properties of silver have long been recognized. And the silver coating releases silver over three weeks after the implantation [6]. However, the silver-coated grafts are not approved for use in Japan. Antibiotic-bonded graft represents an attractive surgical adjunct for treatment of infected aneurysm or graft when in situ replacement is deemed feasible. Among a variety of antibiotics, rifampicin is useful and effective in such situations, offering a broad spectrum of activity against organisms. In addition, this agent is relatively hydrophobic and can thus be expected to remain without rapidly dissolving into the circulation [7]. Since the initial report by Strachan of a rifampicin-bonded prosthesis, several papers of in vitro and clinical experience have reported rifampicin-soaked grafts as a feasible option for treating major graft infection with good early results [5, 7, 8]. Given these considerations, rifampicin-soaked graft is effective in tiding the patient with aortoenteric fistula over the potentially lethal early-term period. Although a small number of reports have commented on the use of rifampicin-soaked grafts for abdominal aortoenteric fistula, reports on AEF are extremely rare [8]. Long-term follow-up of the clinical possibilities and effectiveness of rifampicin-soaked grafts for AEF is thus of critical importance.
The esophageal repair should be individualized based on the extent of esophageal destruction. Although the two basic approaches are primary repair and esophageal resection, primary repair will be feasible in some patients with less esophageal necrosis and purulence. Reardon et al. have reported a fourth successful primary repair, and commented that this will simplify the procedure and allow better swallowing than esophageal reconstruction without long nutritional management, when successful [3]. In our patient, esophageal fistula was firmly attached to the aneurysm, but was 1.5 cm in diameter with no findings of purulence. We, therefore, selected primary repair with distal decompression via a nasogastric tube and tube jejunostomy for enteral feeding. Additionally, omental flap is preferable given the late mortality associated with AEF repair, as the prognosis of patients with AEF depends on the control of surgical infection [9]. de Silva et al. have indicated that it is important to avoid direct contact of the suture line of the esophagus with the prosthesis, and the dead space around a prosthesis should be filled with healthy, well-vascularized tissue [10]. In our case, complete omental coverage was used because the complete omental wrap would be expected to offer the most reliable method to protect against reinfection, resulting in better long-term outcomes. Moreover, another key to the strategy for AEF involved nutritional management via transenteral nutrition with distal decompression of the esophagus and stomach postoperatively. Tube jejunostomy performed simultaneously with AEF closure is convenient and beneficial in nutritional management over the long-term. In particular, this procedure would be mandatory for patients needing a second alimentary tract reconstruction or multiple operations for infection with AEF.
Endovascular repair is an evolving technique and represents an alternative choice for thoracic aortic aneurysm [1, 2]. Although endovascular repair is less invasive and thus the preferred option in management of the aneurysm and control of bleeding through the fistula, the aneurysm and fistula remain in situ, placing the stent graft at risk of infection. However, evolution of endovascular stents with adjunctive options for persistent infection is expected in future.
In summary, an in situ rifampicin-soaked graft appears beneficial, and offers a potential alternative to cryopreserved homograft in the surgical management for AEF from thoracic aneurysms. Moreover, we recommend simultaneous omentopexy and tube jejunostomy as essential to protect reinfection and manage enteral nutrition, prompting early recovery and contributing to long-term survival in patients with AEF.
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References
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Abstract
1. Introduction