Objective: To report a one stage surgery without esophagectomy done to an aortoesophageal fistula secondary to a descending thoracic aneurysm.
Clinical Features: The patient is a 48 year old male who is a known case of Descending Thoracic Aortic Aneurysm, Debakey III Stanford B for 2 years. The patient came in with symptoms of chest pain radiating to the back and one episode of hematemesis. During admission, patient had an episode of massive hematemesis and an Aortoesophageal Fistula was entertained. CT Aortogram was done which showed an increase in size of the previous fusiform aneurysm in the descending thoracic aorta with stable appearance of the long segment of dissection but did not reveal any fistula. The patient underwent upper gastrointestinal endoscopy revealing an esophageal fistula with active bleeding. With the symptoms of the patient characterized by the Chiari's triad of Aortoesophageal Fistula (chest pain, sentinel hematemesis followed by massive hematemesis), the patient was subsequently scheduled for surgery.
Intervention and Outcome: The patient underwent emergency surgery through a left thoracotomy under femorofemoral cardiopulmonary bypass. Upon opening of the aneurysm, the aortic opening of the aortoesophageal fistula was noted. The descending aortic aneurysm was resected and aorta was replaced with a prosthetic graft. The aortoesophageal fistula was closed by suturing only the aortic opening with felted prolene sutures. No esophageal surgery was done. Post-operatively, nasogastric tube was maintained and patient was initially started on formula feeding. Intravenous antibiotics were continued.Seven days after the operation, the nasogastric tube was removed and patient was started on progressive diet per orem. The post-operative recovery of the patient was uneventful. The patient was discharged asymptomatic and able to tolerate regular diet. On follow-up, patient was asymptomatic and no surgical complication was noted.
Conclusion: Aortoesophageal fistula in a patient with thoracic aortic aneurysm can be treated with a one stage surgery without esophagectomy. Closure of the aortoesophageal fistula can be achieved by suturing the aortic opening of the fistula with felted prolene sutures leaving the esophageal opening to close spontaneously.