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Objectives: Atrio-oesophageal fistula is a rare but serious complication of radiofrequency catheter ablation of atrial fibrillation. Therapeutic options are surgery, oesophageal stenting and conservative treatment (antibiotics and anticoagulation). However, there are no guidelines available. Since no article dwells on the technical considerations of this surgery, we aim to present here our experience and share our surgical approach., Methods: Between January 2012 and March 2020, all consecutive patients treated for atrio-oesophageal fistula following radiofrequency catheter ablation of atrial fibrillation at our institution were analysed retrospectively. The diagnosis was made on a set of clinical and radiological signs. All patients benefitted from a combined approach involving both digestive and cardiac surgeons. Femoro-femoral peripheral cardiopulmonary by-pass was used. The surgical approach was a right posterolateral thoracotomy. Atrial repair was done on fibrillating heart without cross-clamping, using a left atriotomy. Digestive management consisted of a total oesophagectomy., Results: We identified 6 patients with this complication. The median age was 53 [34-72] years. Symptoms were neurological symptoms, fever and chest pain. Diagnostic modalities were cerebral imaging, chest CT and transthoracic echocardiogram. Atrial repair consisted in a suture of the atrium or by using a pericardial patch. With a median follow-up of 3.1 [0.1-7.7] years, only one patient died during the follow-up., Conclusions: Our experience shows that an aggressive surgery with a large resection of the oesophagus and left atrial repair by right thoracotomy in the same time provides good results. The ability to involve simultaneously both experienced digestive and cardiac surgical teams is the key for this strategy., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Aorto-oesophageal fistula is a rare but fatal disease. Open surgical repair or endotube repair of aorta and oesophagus save patients from circulatory deterioration, major haematemesis and severe infection. Here we present a rare case of an aorto-oesophageal fistula in the right hemi-arch caused by a fish bone treated with an alternative surgical strategy. Total aortic arch repair using the frozen elephant trunk procedure combined with oesophageal repair were performed. No aortic fistula, oesophageal fistula or artificial graft infection occurred in the follow-up., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A 54-year-old man presenting with dysphagia was diagnosed with locally advanced oesophageal carcinoma with a broncho-oesophageal fistula (c-T4bN2M0 stage IVa). Concurrent chemoradiotherapy (60 Gy) was planned; however, bleeding from the oesophageal lesions progressed during chemoradiotherapy (16 Gy). Oesophagectomy with carinal resection and double-barrelled reconstruction was performed. Despite the inevitable recurrent nerve palsy and a minor fistula at the tracheal anastomosis, he recovered with conservative treatment and was discharged 4 months after the salvage surgery. He is alive without recurrence 28 months after the surgery., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

This study aimed to report the case of a patient diagnosed with pulmonary sequestration accompanied by an intermittent haematemesis as the initial and life-threatening symptom. Emergent surgical intervention finally confirmed a rare direct fistula formation between the arterial blood supply of pulmonary sequestration and the oesophagus, which led to intermittent upper gastrointestinal haemorrhage. To our knowledge, this is the first case reported with this kind of fistula formation., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Aorto-oesophageal fistulae represent <10% of all aortoenteric fistulae and occur in 1.9% of patients who undergo thoracic endovascular aortic repair for treatment of thoracic aortic aneurysms. Untreated patients have a mortality close to 100%. A 74-year-old man had aorto-oesophageal fistulae secondary to thoracic endovascular aortic repair. He had a functioning left internal thoracic artery graft to the left anterior descending artery and a calcific distal aortic arch. He underwent replacement of the thoracic aorta and sealing of the fistulous tract with omentum, and the latter was used to wrap the neoaorta.

Oesophageal foreign body is an emergency situation. Once oesophageal perforation occurs, damage and subsequent infection involving surrounding tissue or organs may ensue. We present here a rare case of aorto-oesophageal fistula which was treated with challenges. An old lady with fishbone induced oesophageal perforation, aortic pseudoaneurysm and mediastinal haematoma was treated with great vessel stent-graft placed in aortic arch, and the fish bone was removed under endoscopy thereafter. During the early follow-up period, part of the graft stent was discovered in the oesophageal perforation with no haemorrhage. The patient is still in good condition during follow-up., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A 58-year-old man presented with fever and chest pain 11 days after atrial fibrillation catheter ablation. The diagnosis of pericardio-oesophageal fistula was made. Aggressive surgical management was decided. The patient was managed using extracorporeal life support, aortic valve replacement and a pulmonary patch, as well as an oesophageal stent. The patient was discharged from hospital approximately 2 months later. The use of a pulmonary patch is a rare but a highly effective technique that can be used in this indication., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Secondary graft-oesophageal fistula is a fatal complication of aortic arch replacement. We report a successful two-stage surgical management of a graft-oesophageal fistula seen in a 68-year-old woman 3 years after total aortic arch replacement. She presented with a prolonged intractable fever without haematemesis. The fistula occurred between the distal aortic anastomosis and oesophagus; the entire graft was surrounded by air. In the first-stage operation, we performed re-replacement of the entire infected graft, oesophagectomy with cervical oesophagostomy, omental transfer and cervical routing of the stomach roll, through an extended left thoracotomy incision with sternal transection. Intravenous antibiotics were administered for 6 weeks; the second-stage cervico-oesophageal anastomosis was performed 57 days later. She was discharged without complications and is doing well 6 months postoperatively., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Oesophageal fistulae after thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysm (TAA) have been reported, although the causes are unknown. One hypothesis is that the structural configuration of the aortic aneurysm, as it protrudes towards the oesophagus, may affect oesophageal fistula formation. The pathological findings of an oesophageal fistula following TEVAR are reviewed here. This report presents the case of a 68-year-old man with a stent graft-related oesophageal fistula after TEVAR for TAA. The oesophageal fistula suddenly appeared on the 11th day after TEVAR, and oesophagectomy was performed, without stent graft extirpation. The pathological findings showed neutrophil infiltration from the adventitia to the mucosa and congestion in the capillaries of the oesophageal wall around the site of penetration and no bacterial infection. There have been reports with logical hypotheses about the causes of stent graft-related oesophageal fistulae. Our pathological findings support the theory that pressure necrosis or ischaemic insult by physical compression of a rigid thrombosed aneurysm may result in fistula formation. For descending aortic aneurysms that protrude toward the oesophagus, caution must be exercised to prevent oesophageal fistula formation after TEVAR., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A 79-year-old moderately frail man with a history of graft replacement for descending thoracic aortic aneurysm and chronic kidney disease presented with the onset of haemoptysis. Computed tomography demonstrated aorto-oesophageal fistula secondary to aortic arch aneurysm rupture. Emergency surgery was performed through a median sternotomy. Cardiopulmonary bypass was established via femoral artery inflow and bicaval venous drainage. After establishing circulatory arrest, the aortic arch was excised. Resection of the aortic aneurysm and debridement were performed during antegrade cerebral perfusion and lower body perfusion from femoral artery inflow using balloon occlusion of the previous graft. Aortic arch graft replacement with concomitant debridement of mediastinal tissue and direct repair of oesophageal perforation comprised a first-stage operation. Forty hours later, abundant irrigation of warm normal saline around the mediastinal cavity and the omental flap covering the graft and the repair site of the oesophagus comprised the second-stage operation. Although the postoperative course was complicated, the patient resumed oral intake within 2 months after the initial operation. Serial computed tomography and oesophageal endoscopy showed good healing of the aorto-oesophageal fistula. There were no clinical manifestations or imaging findings of deep mediastinal infection throughout the postoperative course., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A 63-year old man had dysphagia for 4 months and was admitted to our hospital with sudden haematemesis. Computed tomography revealed an aberrant right subclavian artery (ARSA) aneurysm and free air inside the aneurysm. Arterio-oesophageal fistula was diagnosed, and an emergency operation was performed. Before thoracotomy, a percutaneous transluminal angioplasty (PTA) balloon was inserted from the right brachial artery and placed at the orifice of the ARSA to control bleeding. Through a left thoracotomy, the aorta was excised and the orifice of the ARSA was exposed. There was no sign of infection in the operative field. Bleeding from the ARSA was controlled by balloon occlusion. The proximal portion of the right vertebral artery was ligated and blood backflow from the ARSA stopped. The ARSA was ligated proximal to the aneurysm, and the orifice of the ARSA to the aorta was closed. The infected aneurysm was not resected. The descending aorta was replaced by a rifampin-bonded artificial graft, and omentopexy was performed. Gastrostomy was performed for decompression of the oesophagus and enteric feeding. Three months after the operation, gastrointestinal endoscopy showed a healed oesophageal ulcer, and the patient was discharged uneventfully.

Oesophagopleural fistula is a recognized complication of pneumonectomy. Surgical repair with direct closure and reinforcement with omentum, muscle or pleural flap is the mainstay of definitive treatment. However, this option might not be suitable for all patients. The authors report on the case of a 63-year old female refusing surgical repair of an oesophagopleural fistula after left pneumonectomy. A novel approach (using an Amplatzer atrial septal occluder device) for fistula closure was attempted. Despite a promising initial result, the procedure failed. This is the first report on the use of a septal occluder to try and close an oesophagopleural fistula.

Objectives: Fistulas between the oesophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after oesophageal resection, without any signs of local residual tumour growth. Other causes that are, by definition, benign may rarely prevail. The traditional therapeutic approach is to divert the proximal portion of the oesophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. We have evaluated our stent-based strategy for managing these life-threatening situations., Methods: At Karolinska University Hospital, all patients admitted with an oesophago-respiratory fistula during the period 2003-2011 followed a stent-based strategy. On clinical suspicion, a prompt computed tomography scan was performed with contrast ingestion, to visualize the status of the anastomosis and the potential communications. Often an endoscopy was done to assess the oesophagus and the conduit. The respiratory tree was inspected through a concomitant bronchoscopy. The double-stent strategy presently applied meant that covered self-expandable metal stents (SEMS) were applied on the alimentary and airway sides to adequately cover the fistula orifice on both sides. The subsequent clinical course determined the ensuing therapeutic strategy., Results: During the study period, 17 cases with oesophago-respiratory fistulas were treated at our unit, of which 13 exhibited fistulation following an oesophageal resection due to cancer and 4 cases had a benign underlying disease. The cancer patients did not show any obvious demographic profile when it came to the cancer sub-location, histological type of cancer, or treatment with neoadjuvant chemo- and radiochemotherapy. There was an equal distribution between hand-sutured and stapled anastomoses. In 10 of the cases, the anastomoses were located in the upper right chest; the remainder in the neck, and all reconstructions were carried out by a tubulized stomach. The diagnosis of the fistula tract between the anastomotic area and the respiratory tract was attained on the 15th postoperative day (median), with a range from 5 to 24 days., Conclusions: When an oesophago-respiratory fistula is diagnosed, even in a situation where no neoplastic tissue is prevailing, attempts should be made to close the fistula tract by SEMS from both directions, i.e. from the oesophageal as well as the respiratory side. By this means, a majority of these patients can be initially managed conservatively with prospects of a successful outcome, although virtually all will eventually require a single-stage resection and reconstruction.

False aortic aneurysm is an uncommon complication after oesophageal perforation and results in a high rate of mortality. A 63-year-old patient presented with acute chest pain. Biochemical tests (cardiac enzymes) and electrocardiogram were normal. A thoracic and abdominal CT scan was performed, and showed a foreign body in the posterior mediastinum, with mediastinal cellulitis and a false aortic aneurysm. Surgical endovascular management was performed, with stenting of the thoracic aorta and oesophageal exploration.

Aorto-oesophageal fistula (AEF) is a rare but life-threatening disease with an underlying infective aetiology that can cause serious complications. This study investigated the clinical outcomes of patients with AEF who received in situ cryopreserved aortic allograft replacement. From August 2000 to February 2011, 11 patients with AEF received aortic allografts; 5 for primary AEF caused by ruptured aortic aneurysm and 6 for secondary AEF that comprised 4 cases following thoracic endovascular aortic repair (TEVAR) and 2 after open graft replacement of the thoracic aorta. As for results, 2 cases of primary AEF received TEVAR and then allograft replacement, one for graft infection and the other for bleeding. Three primary AEF cases received allografts directly. Six secondary AEF cases received staged (5) or simultaneous (1) oesophagectomy and allograft replacement. There were 3 in-hospital deaths (27%), 2 because of bleeding and one because of multisystem organ failure. Four patients completed oesophageal reconstruction. There were 2 late deaths, one due to aspiration pneumonia and one of unknown cause. In conclusion, surgical results for repair of AEF using cryopreserved aortic allograft were satisfactory considering preoperative critical condition, and this type of allograft appears to be an ideal graft of choice.

A 75-year-old male, known to have achalasia, was admitted to the intensive care unit with massive upper gastrointestinal bleeding and sepsis. He had a history of purulent pericarditis 18 months earlier. He also presented with atrial fibrillation associated with a cerebral transient ischemic accident two months earlier. A contrast computed tomography scan showed an atrio-esophageal fistula with active extravasation of contrast. He was operated on via a median sternotomy, and the defects in the atrial wall, inferior vena cava and diaphragm were closed using pericardial patches. An esophagectomy was to be performed 24 hours later, but the patient died from septic shock and multiple organ failure before his second procedure.

This case report describes the repair of an aortoesophageal fistula caused by a previously placed aortic arch graft. A 62-year-old man underwent total aortic arch graft replacement one year ago. He was readmitted with hematemesis and a high fever. Examination by endoscopy revealed a perforation and two swollen lesions in the mid-esophagus. With the diagnosis of aortoesophageal fistula, the patient underwent esophagectomy, cervical esophagostomy, and gastrostomy with plans for esophageal continuity. Twenty days later, the patient had the graft replacement. Left thoracotomy was performed at the fourth intercostal space and the incision was extended to a sternal transection. The old aortic arch graft was replaced with a rifampicin-bonded gelatin-sealed Dacron graft. After successful esophageal reconstruction (a cervical esophagogastrostomy with the stomach in the substernal position), he fully recovered from surgery. Aortoesophageal fistula is rare and always fatal if surgical intervention is not attempted. When homografts are unavailable, an alternative therapeutic approach is in situ replacement with a rifampicin-bonded gelatin-sealed Dacron graft.

We report on the successful surgical treatment of an esophageal-bibronchial fistula originating from an iatrogenic mediastinal abscess. Endoscopic treatment had been excluded due to the extensive damage to the right main stem bronchus wall. The surgical treatment was carried out as follows: 1) Endoscopic stenting of the left main bronchus with a self-expanding metallic stent followed by selective left main bronchus intubation; 2) Laparotomic harvesting of the omentum pedicled on both gastro-epiploic vessels; 3) Right thoracotomy, complete dissection of both main bronchi and esophageal wall at the site of the leakage; 4) Harvesting of a pericardial vascularized graft; 5) Deployment of a self-expanding metallic stent from the surgical field into the right main stem bronchus; 6) Reconstruction of the right bronchus wall with the pericardial patch; 7) Positioning a T-tube in the esophageal leak; and 8) Intrathoracic transposition of the omental graft for buttressing all sutures and potential leakage points. The postoperative course was uneventful from a surgical point of view and the patient recovered completely.

We report the case of a 27-year-old pregnant woman, presenting a rare but potentially fatal complication of an omental wrapping, transposed in the thorax by a phrenotomy due to an intra-oesophageal rupture of a bronchogenic cyst. Two years later, on time of delivery of her first pregnancy, she has presented a diaphragmatic rupture with a complete transposition of the volvuled stomach. The diagnosis was done using the Gastrographin transit and the CT-scan, showing the specific 'Collar sign'. An urgent surgical correction was performed including the re-instatement of all abdominal organs in the peritoneum, the omental wrapping section and the diaphragmatic closure. The two-year follow-up was uneventful. We discuss the case, the investigations needed and the possibility to cut the omental wrapping without any complication two years after this oesophageal re-inforcement. In conclusion, we believe that omental transpositions must always be done using the retrosternal route or by transhiatal approach to avoid this serious complication after delivery.

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.