Successful Open-Surgical Treatment for a Secondary Aorto-esophageal Fistula and Broncho-mediastinal Fistula

Yuta Kanazawa＊,＊＊	Yasuyuki Yamada＊,＊＊	Ikuko Shibasaki＊
Koji Ogata＊	Toshiyuki Kuwata＊,＊＊＊	Hironaga Ogawa＊
Yusuke Takei＊	Yasuyuki Kanno＊	Hirotsugu Fukuda＊

（Department of Cardiac and Vascular Surgery, Dokkyo Medical University Hospital Heart Center＊, Tochigi, Japan, Division of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center＊＊, Maebashi, Japan, and Department of Cardiovascular Surgery, Japanese Red Cross Maebashi Hospital＊＊＊, Maebashi, Japan）

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.

 

Jpn. J. Cardiovasc. Surg. 48:351-355（2019）

Keywords：aorto-esophageal fistula;broncho-mediastinal fistula