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Objectives: The presence of a fistula between the thoracic aorta and the esophagus is a rare and highly fatal condition. This study aimed to evaluate the outcomes of the surgical treatment of an aortoesophageal fistula (AEF)., Methods: We retrospectively reviewed patients with AEF who underwent surgery at our institution., Results: Between 2007 and 2018, a total of 10 patients who underwent surgery for AEF. The mean age was 63 ± 12 years, and 6 patients were men. Four patients had primary AEFs and 6 patients had secondary AEFs (3 graft replacements and 3 thoracic endovascular aortic repairs). The timing of AEF since graft replacement or thoracic endovascular aortic repairs was 21.6 ± 27 days. We performed aortic replacement with a prosthetic graft (4 patients) or a homograft (5 patients) and extra-anatomical bypass due to a previous aortic graft infection (1 patient). As a treatment of the esophagus, we conducted primary repair in 7 of 10 patients. The median lengths of hospital and intensive care unit stay were 59 days (range, 9-225 days) and 6.3 days (range, 1-87 days), respectively. Seven patients achieved oral feeding after a median 10.3 postoperative days (range, 7-78 postoperative days). Two of the 10 patients died of sepsis at 9 and 74 days postoperatively., Conclusions: The strategy for patients with AEF should be individualized. Our surgical strategy for AEF, which includes simultaneous aortic graft replacement and primary repair of esophagus in the same operative field, is feasible and promising., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To present a surgical strategy for aortoesophageal fistula (AEF)., Methods: From October 1999 to May 2017, 27 patients with AEF were treated at Kobe University Hospital. After 9 patients with malignancies or fish bone penetration were excluded, 18 patients who had AEF secondary to aortic lesions were investigated. The mean age was 67.2 ± 10.4 years, and the male/female ratio was 16:2. Twelve patients had a nondissection thoracic aneurysm, and 6 patients had a chronic aortic dissection. Six patients were in shock. Seven patients had a previous thoracic endovascular aortic repair (TEVAR) in the descending aorta, 2 patients had descending aorta replacement, 1 had hemiarch replacement, and 2 had total arch replacement. As the first treatment for AEF, 3 patients underwent TEVAR as destination therapy, 3 patients had a bridge TEVAR to open surgery, 1 patient had an extra-anatomical bypass from the ascending aorta to the abdominal aorta, and 11 patients had an in situ reconstruction of the descending aorta. The esophagus was resected in 16 patients, and an omental flap was installed in 16 patients. Additional procedures were extra-anatomical bypass in 2 patients and in situ reconstruction of the aorta in 3 patients., Results: Hospital mortality was noted in 4 patients (22.2% persistent sepsis, n = 3: pneumonia, n = 1). However, since 2007, only 1 of 13 patients has died (pneumonia). Late death occurred in 5 patients, due to pneumonia, cerebral bleeding, diarrhea, sudden death, and persistent infection. Actuarial survival was 42.4 ± 12.8% at 5 years and freedom from aorta-related death was 59.4 ± 13.5% at 5 years. Nine patients achieved completed reconstruction of the esophagus 172 ± 57 days after initial surgery., Conclusions: Although a comparative study was not performed, 1-stage surgery consisting of resection of an aneurysm and esophagus, in situ reconstruction of the descending aorta, and omental flap installation provided a better outcome in the treatment for AEF. Bridging TEVAR to the open surgery is a useful adjunct in patients with AEF with hemorrhagic shock. Later reconstruction of the esophagus can be performed in the survivors., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Anastomotic leakage with an intractable cutaneous fistula frequently develops after an esophagectomy and reconstruction via the subcutaneous route., Methods: A pectoralis major muscle (PMM) flap was used for the treatment of 6 patients with esophageal cancer who developed anastomotic leakage with fistula after reconstruction via the subcutaneous route. A gastric tube and colon had been used for reconstruction in 2 and 4 patients, respectively. A trimming and repair of the leakage site was initially performed and the anastomotic site was then covered with a muscle flap., Results: Recurrent anastomotic leakage did not develop in 5 patients. Among these patients, oral intake was initiated from 11-15 days after the repair operation in 4 patients. A patient having recurrent anastomotic leakage after a repair operation recovered well with conservative therapy., Conclusion: The coverage with a PMM flap over the repair site is a simple method for preventing the development of recurrent leakage after a repair operation. Even when recurrent anastomotic leakage has occurred after this operation, healing is normally expected by means of conservative treatment. We, therefore, recommend this method for the repair of intractable anastomotic leakage after reconstruction via the subcutaneous route for esophageal cancer., (Copyright 2010 Mosby, Inc. All rights reserved.)

Objectives: Benign bronchoesophageal fistula is a rare complication resulting from various diseases. The objectives of the study are to report our surgical experience in patients with benign bronchoesophageal fistulas and to evaluate the long-term results of surgical management., Methods: Between 1995 and 2005, a total of 14 patients (mean age, 52.5 years; male/female = 6:8) underwent operations for benign bronchoesophageal fistulas. The etiology of the fistulas included traction esophageal diverticula in 7 patients and tuberculous lymphadenopathy in 6. Primary repair of the fistula was performed in all patients and a concomitant lobectomy in 6., Results: There was no in-hospital mortality. Postoperative complications occurred in 1 patient (empyema resulting from a leakage at the repair site). Postoperative esophagography revealed a leakage at the repair site in 1 patient. There was 1 late death with a mean follow-up of 43.9 months. The cause of death was aspiration pneumonia resulting from recurrent fistula. Two of 8 patients who did not undergo a lobectomy had persistent bronchiectasis, whereas none of those who underwent a concomitant lobectomy had any recurrent pneumonia or bronchiectasis. The overall survival was 100% at 5 years and the mean survival time was 124 months (95% confidence interval, 106.5-142.2 months)., Conclusions: We conclude from these data that early detection and definitive surgical repair of benign bronchoesophageal fistulas can yield high success rates with excellent early outcomes and good long-term results.

Objective: Leak after esophageal anastomosis or perforation repair prolongs hospitalization, prevents oral hydration and nutrition, and can produce localized infection or sepsis. This investigation reviews our experience treating postoperative esophageal leaks with the Polyflex esophageal stent (Boston Scientific, Natick, Mass)., Methods: Over a 30-month period, patients with a postoperative esophageal leak were treated with the Polyflex stent for leak occlusion. Leak occlusion was confirmed by means of esophagraphy. Patients were followed until their stent was removed and their esophageal leak had resolved., Results: Twenty-one patients had 27 stents placed for leak occlusion after esophagectomy (n = 5), esophageal perforation (n = 5), surgical (n = 4) or endoscopic (n = 2) antireflux procedure, and esophageal diverticulectomy (n = 3) or myotomy (n = 2). The mean interval between surgical intervention and stent placement was 12 +/- 8 days (range, 3-31 days). Occlusion of the leak occurred in 20 patients. One patient experienced a dehiscence of the surgical esophageal perforation repair requiring esophageal diversion. Stent migration requiring repositioning (n = 3) or replacement (n = 4) occurred in 5 (24%) patients. Twenty (95%) stents were removed without residual leak (mean, 51 +/- 43 days; range, 15-175 days). One patient had a stricture after stent removal that required endoscopic dilatation. One patient in this series died., Conclusions: The Polyflex esophageal stent is an effective method for occluding a postoperative esophageal leak. It rapidly eliminates contamination of the mediastinum, pleura, and peritoneum; allows oral hydration and nutrition; and is easily removable. These stents also offer an appealing alternative to traditional esophageal diversion and subsequent reconstruction in patients with a persistent esophageal leak.

An aortoesophageal fistula is a life-threatening cause of gastrointestinal bleeding where an abnormal communication between the esophagus and the aorta may result from a thoracic aortic aneurysm, foreign body ingestion, esophageal malignancy, or postoperative complications. The diagnosis can be made on the basis of clinical findings alone. Classic patients present with the triad of midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval (Chiari's triad). The identification of massive upper gastrointestinal hemorrhage that is bright red and arterial in nature is characteristic. Most diagnostic tests have significant individual limitations. Endoscopy of the upper gastrointestinal tract should exclude alternative bleeding sources and may show a submucosal hematoma. Aortography may be useful during active hemorrhage to demonstrate the fistula, but results of aortography may be negative during the symptom-free interval. Dynamic computed tomography may be a more rapid alternative. For patients who are in stable condition after the sentinel hemorrhage, a confirmatory test is reasonable. Patients in unstable condition should undergo immediate surgery. Survival is now possible with rapid surgical intervention.

Objective: The majority of cervical esophageal anastomotic complications can be successfully managed nonoperatively. A small group of patients may have anastomotic strictures or leakage and fistula formation that are chronic and resistant to nonoperative therapy. The purpose of this study was to review our experience with the use of the pectoralis myocutaneous flap to treat these patients., Methods: Since April 1992, four patients have undergone pectoralis myocutaneous flap repair of cervical esophageal anastomotic complications at our institution. Two patients had chronic strictures, one patient underwent prophylactic repair with a pectoralis myocutaneous flap to prevent stricture formation, and one patient had a chronic anastomotic fistula. The pectoralis myocutaneous flap was harvested in the standard fashion. The technique of anastomotic repair is described. The medical records were retrospectively reviewed to determine patient characteristics and our results., Results: Two suture line leaks developed: one small, contained leak required no intervention, and the other resolved with cervical drainage. Pneumonia, seroma at the site of the pectoralis myocutaneous flap donor, transient hoarseness, and partial skin graft loss occurred in one case each. There were no deaths. Hospital stay ranged from 12 to 22 days. A good functional result was obtained in three patients., Conclusion: Our results show that pectoralis myocutaneous flap repair of select cervical anastomotic complications is safe and well tolerated even in patients with complicated problems.

Background: We describe an instrument for mobilizing the normal esophagus without thoracotomy. It is essentially a metal ring introduced through the neck that encircles the esophagus, separating it from surrounding tissues., Methods: Preliminary studies of 12 cadavers were followed by clinical application in 18 patients with esophageal carcinoma and two with benign esophageal lesions., Results: Pneumothorax occurred in 20%, recurrent laryngeal nerve palsy in 25% (4 of 5 were transient), and thoracotomy for postoperative bleeding from the tumor bed in two cases. No anastomotic leakage occurred. Mortality rate at 30 days after operation was 15%, with an in-hospital mortality rate of 20%. Use of the instrument did not cause any of the described complications. In one patient the esophageal carcinoma was adherent to the trachea, which was injured. No incidence of hypotension or arrhythmia was observed during thoracic esophageal dissection. Blood loss from the mediastinum wa unremarkable. The treatment by stripping is a palliative treatment and precludes a radical curative attempt. The use of this instrument is contraindicated in lesions of the upper and middle parts of the esophagus, and it is not intended to strip a bulky esophagus as in achalasia., Conclusions: The esophageal dissector made mobilization of the normal thoracic esophagus easier and less time consuming, and yielded no episodes of hypotension or arrythmia.

Congenital tracheoesophageal or bronchoesophageal fistulas, if not associated with esophageal atresia, may not appear initially until adult life. Nine such cases (two tracheoesophageal and seven bronchoesophageal) are reported. The chief presenting symptoms were recurrent bouts of coughing, after drinking, and hemoptysis. In the majority of cases the duration of symptoms exceeded 15 years. The diagnosis was confirmed in seven patients by esophagography, in one patient by bronchoscopy, and in one patient the fistula was discovered incidentally during thoracotomy. The esophageal opening of the fistula was in the lower third in seven patients and in the middle third in two. Bronchoesophageal fistulas communicated with a segmental bronchus in four patients and with a main or lobar bronchus in three. Treatment involved excision of the fistula (five patients) or division and suturing (four patients). Postoperative follow-up revealed no long-term sequelae except persistent chronic respiratory failure in one patient. The respiratory failure had developed before treatment of the fistula. The analysis of this series and a review of the literature underline the high index of suspicion required in all cases of chronic cough and lung suppuration, to diagnose this benign condition before life-threatening complications occur.

An anastomotic leak into the right pleural space developed following esophagogastrectomy for cancer in a 56-year-old patient. Subsequently, a similar fistula occurred into the pericardium. This was managed successfully by a modification of Abbott's T-tube technique, together with a pericardial window, multiple drainage tubes, systemic antibiotics, and hyperalimentation. The anastomotic disruption healed completely, with only minimal narrowing on repeat roentgenograms of the upper gastrointestinal tract. Only four survivors of this rare and highly lethal problem have been previously reported.

Methods of restoring luminal lining in repair of partial-circumferential esophageal defects were evaluated to compare incidences of strictures and fistulas and quality of surface lining. In cats 50% and 67% circumferential esophageal defects were repaired by direct closure or pedicle flaps (latissimus dorsi) that were unlined (lining restored by epithelialization from wound margins) or that carried lining of normal skin (myocutaneous flaps), skin grafts, or mucosal grafts. Repairs were evaluated for esophagocutaneous fistulas, luminal stricture, flap luminal surface area, and quality of epithelial surface 6 weeks after surgery. Direct closure of 50% circumferential defects was as satisfactory as any flap repair method. Direct closure of 67% circumferential defects caused high incidences of fistulas and strictures, which were lessened by flap reconstructions. Among flap lining methods, normal skin (myocutaneous flaps) gave the lowest incidence of fistulas and strictures and the highest surface quality, but a high incidence of skin paddle loss occurred in this model. Split-thickness epithelial grafts were nearly as satisfactory as myocutaneous flaps, and less lining loss occurred. Epithelialization of unlined flaps gave the poorest results since lining was thin and often incomplete, and wound contraction produced loss of surface area and strictures. The findings are discussed from a perspective of wound healing physiology, and implications for clinical application are presented.

During the past 6 years, 31 patients (20 males and 11 females) underwent 45 intrathoracic muscle transpositions of extrathoracic skeletal muscle. Eleven patients had postpneumonectomy empyema, 11 had bronchopleural fistula, four had infection of the heart and great vessels, three had reinforcement of tracheal anastomoses, and two had perforation of the gastrointestinal tract. Life-threatening infection was present in 28 patients. Ages ranged from 16 to 80 years, with a mean of 58.1. The latissimus dorsi muscle was transposed in 18 patients, pectoralis major muscle in 15, serratus anterior muscle in eight, pectoralis minor muscle in three, and rectus abdominis muscle in one. Twelve patients had multiple muscle transpositions (six concurrently and six staged). Operative mortality was 12.9% (four patients). Follow-up of the 27 operative survivors ranged from 3 to 72 months with a mean of 17.3. Twenty-four patients had no further signs or symptoms of the original infection. All had a closed chest. Long-term survivors included 73% of patients with postpneumonectomy empyema, 64% of patients with bronchopleural fistulas, and 50% of patients with infections of the heart and great vessels. We conclude that intrathoracic transposition of an extrathoracic skeletal muscle is an excellent method of treatment for persistent, life-threatening intrathoracic infection.

During a 4 year period between 1970 and 1974 there were eleven esophageal gunshot wounds representing 52 per cent of the total esophageal perforations. The increased incidence of esophageal gunshot wounds reflects the higher rate of civilian gunshot injuries. There were six perforations in the cervical portion of the esophagus and five in the thoracic portion, with three located above the aortic arch, one in the midesophagus, and one in the lower third. Symptoms are less diagnostic than in esophageal perforations from other causes because the gunshot wound tends to mask the complaints related to mediastinitis. The signs are similar. In 9 patients free air was present in the neck or mediastinum and in 10 patients the diagnosis was confirmed by barium swallow. Of the 2 patients without free air, one had a lateral thoracic wound and esophageal injury was not suspected; the diagnosis was made by drainage of oral feeding through a thoracostomy and confirmed by barium swallow. In the other patient the perforation was found during surgery for hemothorax. Primary repair with drainage was done in the group with cervical injuries. All survived with no serious complications. In the group with thoracic injuries, fistulas developed in 2 of 3 patients who had primary repair with drainage. Two patients with extensive injuries of the esophagus treated by defunctionalization did well but required a second procedure. It is concluded that gunshot wounds of the cervical esophagus, if treated promptly by suture and drainage, will do well. Thoracic injuries represent a more difficult problem and it is suggested that defunctionalization of the esophagus is the safest procedure, particularly if damage is extensive.

Congenital esophagobronchial fistula occurring in infancy and childhood is a well-recognized entity necessitating urgent surgical treatment. Persistence of such a communication into adulthood is rare and would seem possible only if the tract were small so that aspiration into the lung could be tolerated. The case of a 38-year-old woman is presented in this report who was cured of lifelong symptoms of aspiration by surgical division of a presumed congenital esophagobronchial fistula.

Most aneurysms of the descending thoracic aorta rupture unless treated surgically. Autopsy studies in these patients indicate that rupture occurs into the esophagus in 10% of the cases and constitutes the most common cause of aorta-esophageal fistula. A reasonable literature review has not revealed a previously successful treatment for this condition. Experience in the treatment of patients with aneurysms of the descending thoracic aorta partially obstructing the esophagus without fistula formation indicates that simple graft replacement is curative. When the disease has progressed to actual fistula formation and esophageal bleeding, as illustrated in these two case reports, operation is done to prevent exsanguination. Appropriate management involves control of hemorrhage and treatment of the chronic esophageal perforation. The former is accomplished by resection and graft replacement of the ruptured thoracic aneurysm. Alternatives in dealing with the chronic esophageal defect are planned, staged reconstruction in high-risk patients and immediate resection and intrathoracic esophagogastrostomy in selected patients.

Two cases of aorta-esophageal fistula (AEF) resulting from a foreign body in the esophagus are presented. One we believe to be the first recorded survival. Both cases illustrate the importance of early diagnosis, made on the classical history, followed by operation.

Two cases of benign bronchoesophageal fistula are presented which are representative of both congenital and acquired forms. The presentation of this relatively rare condition is characterized by recurrent cough especially after drinking liquids and is easily diagnosed by esophagogram. A high index of suspicion is required in all cases of recurrent cough and lung suppuration in order for this condition to be recognized. Benign bronchoesophageal fistulas are rare but the symptoms are often classic and the diagnosis is made easily once proper investigation is undertaken. Bronchoesophageal fistulas may be either congenital or acquired, with the latter being more common. The treatment is usually straightforward and prognosis is excellent for long-term survival. We present two cases of benign bronchoesophageal fistula.

Although esophageal perforation in children is associated with a spectrum of disease different from the one in adults, management is essentially the same for both groups. Over the past 11 years, 12 patients ranging in age from 2 days to 10 years were treated for 13 perforations. Perforation in the adult is associated with a high mortality rate. All children in this series survived. Injury was secondary to instrumentation in 10 cases and three resulted from the chronic erosion of a trapped foreign body. Of the 10 acute perforations, five occurred 12 days to 5 months after lye ingestion. Anastomotic narrowing was a factor in three other cases. Seven of the acute perforations involved the thoracic esophagus and were associated with a high morbidity rate. Management consisted of operative as well as nonoperative approaches. Consideration must be given to several clinical variables including location, cause, predisposing factors, underlying illnesses, associated injury, and promptness of medical attention.

The development of an esophagopleural fistula after pneumonectomy is one of the less common complications of pneumonectomy. Herein reported are seven cases over a period of 14 years, five from a series of 896 pneumonectomies performed for malignant or inflammatory disease in the Department of Thoracic Surgery and two referred after pneumonectomy elsewhere. The fistula was demonstrated by the escape of radiographic contrast material, methylene blue, or food particles into the pleural space or was observed at esophagoscopy. In all, the associated empyema was first treated by drainage, and surgical repair of the fistula was attempted in only three cases. In six cases the fistula had closed before the patient left hospital. In the seventh, the patient insisted on leaving the hospital while under treatment and before closure had occurred. One patient died of cor pulmonale 2 years after closure of the fistula. There has been no recurrence of the fistula in any of the patients observed. Conservative management is at variance with that of many authors.