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A 58-year-old man was admitted for an aortoesophageal fistula (AEF) resulting from a thoracic aortic aneurysm. He underwent immediate in-situ prosthetic graft replacement, primary esophageal repair and wrapping of the aneurysm. Postoperative upper gastrointestinal endoscopy and computerized tomography (CT) findings were unremarkable. He was discharged on postoperative day (POD) 25. Three months after surgery, he was readmitted with complaints of worsening cough and hemoptysis. CT showed a thrombosed aneurysm adjacent to the left bronchus. Aortobronchial fistula due to mycotic pseudoaneurysm was suspected. The patient underwent immediate resection of the infected graft and prosthetic graft replacement positioned to avoid the infected area. The graft was wrapped with omentum. On POD 7, pleural empyema developed, and esophagography revealed a residual leak. Staged reconstruction of the esophagus was performed successfully. We conclude that even if the fistulous opening is small, simultaneous esophageal resection should be performed during the initial treatment of AEF.

We report adult congenital bronchoesophageal fistula with both symptomatic fistula and asymptomatic one. A 56-year-old woman with a history of cough after drinking fluids was diagnosed as bronchoesophageal fistula by upper gastrointestinal series that showed a diverticulum in the middle portion of the esophagus with a fistula between the esophagus and right lower lung. Esophagoscopy revealed an orifice of the fistula located 27 cm from the incisors. Computed tomography showed chronic inflammatory change with bronchiectasis in the S6 segment of the right lung. The patient underwent video assisted thoracic surgery that identified two fistulae without missing a symptomatic one, and both were successfully resected. The fistulae were lined by squamous epithelium and smooth muscle without evidence of malignancy, infection or chronic inflammation that were histologically compatible with congenital fistulae.

A 45-year-old woman was admitted to our hospital with a diagnosis of bronchoesophageal fistula, after a barium esophagography performed in an annual medical check-up had demonstrated an esophageal diverticulum in the middle of the thoracic esophagus, having a narrow bridge between the right intermediate bronchi. The patient had a history of tuberculosis in her childhood, and chest radiography showed multiple calcified hilar lymph nodes. The fistula was observed on gastroenteroscopy and on bronchofiberscopy. The patient was treated surgically, with ligation and resection of the fistula. The fistulous tract was attached to a calcified hilar lymph node, and both the diverticulum and fistula were concluded to have been caused by the tuberculous lymphadenitis in her childhood. It is very uncommon to have bronchoesophageal fistula, caused by tuberculosis in childhood, diagnosed and treated surgically at more than forty years later.

Aortoesophageal fistula (AEF) secondary to thoracic aneurysm is rare, and is usually fatal without prompt surgical intervention, with few survivors reported. Here we report a case of a 68-year-old woman late-presenting AEF successfully treated by extra-anatomic bypass grafting. Since she had already a mediastinal infection caused by AEF on admission, we performed extra-anatomic bypass grafting from the ascending aorta to the infrarenal aorta, and primary esophageal repair. The extra-anatomic bypass grafting was performed to avoid the risk to secondary graft infection and to decrease the total ishemic time induced by intraoperative aortic clamping, which is necessary when in-situ graft replacement is chosen. Although only 17 cases (including the present case) have been reported as long-term survivors, most have involved in-situ repair of the thoracic aneurysm. To our knowledge, the present case was only the second treated successfully by extra-anatomic bypass grafting. We recommend extra-anatomic bypass grafting for a case with severe infection and prolonged hypoperfusion insult caused by massive bleeding due to rupture in an aneurysm.

We present a case of a congenital bronchoesophageal fistula in an adult male who underwent video-assisted thoracic surgery for a resection of the fistula. The patient had not suffered from any serious respiratory infection since the adolescence. However, at 49 years old, the patient experienced persistent cough and back pain. An abnormal shadow in the right lower lobe was observed on a chest X-ray. Chest computed tomography scanning indicated bronchiectasia in the lower superior segment and an abnormal air duct in the posterior mediastinum. Esophagography revealed a 4-cm-long and 1-cm-diameter fistula between the midesophagus and the right lower lobe. Esophagoscopy and bronchoscopy revealed the orifice of the fistula. Three-dimensional computed tomography scanning demonstrated that there was no abnormal artery supplying blood to the affected lung. He underwent video-assisted thoracic surgery, and was uneventfully discharged. Thoracoscopy offered excellent anatomical visualization of the fistula and safe surgical resection.

Aortoesophageal fistula is rare. A woman who developed aortoesophageal fistula after swallowing a fish bone developed hematemesis. 7 days later, we resected a false aneurysm near the left subclavian artery and repaired this section twice. Despite these measures, the woman died on hospital day 21. The clinical diagnosis was massive hematemesis from an infected aortic wall. The method of diagnosis, control of infection, and operative repair of aortoesophageal fistula are discussed.

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.

Aorto-esophageal fistula due to ruptured thoracic aortic aneurysm is very rare but is associated with extremely high mortality. An 81-year-old woman was admitted due to repeated hematemesis. Endoscopic examination revealed ulceration with blood clot on the mid-esophagus and compression of an extra-esophageal mass. The thoracic CT scan revealed an aorto-esophageal fistula due to a ruptured descending thoracic aortic aneurysm. Surgery was performed on April 3, 1996. We report an aorto-esophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. The esophagus was reconstructed using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft. The postoperative course was uneventful and there have been no signs of mediastinal sepsis, graft infection or pyothorax 12 months postoperatively. We suggest that the resection of both the aneurysm and the esophagus as well as the immediate reconstruction of the esophagus by orthotopic gastric interposition to obliterate the retrosternal space are important technique in the management of intrathoracic infections.

Aortoesophageal fistulas due to thoracic aneurysms are usually fatal, with few reported survivors. A 57-year-old man with aortoesophageal fistula due to thoracoabdominal aortic aneurysm underwent the graft replacement of thoracoabdominal aorta. In the postoperative course, prosthetic graft infection had occurred in the result of residual esophageal fistula. On the 32nd postoperative day (POD), a subtotal esophagectomy was performed and the esophagus was reconstructed by gastrointestinal interposition technique via a retrosternal route. Following the second operative procedure, inflammatory reactions had been improved with systemic administration of antibiotics and continuous irrigation of the infected cavity. On 77th POD, he was discharged.

A 52-year-old man had been having cough on drinking water since 30 years. He coughed out blood 20 years ago. Chest roentgenogram showed the infiltrating shadow in the right lower lung field and the left hilum. Chest computed tomogram in the left atrium level showed fistulous communication between the bronchus and the esophagus and cavity lesion. Esophagogram showed fistulous communication between the bronchus (rt. B7) and the middle third of the esophagus. Bronchogram showed the stenotic lesion of the right B7a and B*. And abnormal bronchus was revealed and fistula was suspected. The orifice of the fistula was seen by esophageal endoscopy. Through the right posterolateral thoracotomy, fistelectomy and covering with pleural flap over the esophageal suturing site were performed. Histologic finding of the resected specimen revealed fistula's wall composing of smooth muscle lined with squamous cell layer. This case is categorized as Braimbridge type II. The postoperative course was uneventful and the patient is now in free of complaints at the 6th month's P.O.D.

In a case of 51-year-old woman with an esophago-bronchial fistula located in the right B2 bronchus, we found a tubular type of esophageal duplication communicating with the esophagobronchial fistula by examinations of esophagography and endoscopy. It was diagnosed as tubular type I double barreled type of esophageal duplication by Akaboshi's Classification. She successfully underwent resection of the accessory esophagus combined with the fistula and the adjacent pulmonary tissues. Squamous epithelium and smooth muscle tissue were observed in the resected esophageal specimen. Double barreled type of esophageal duplication is one of the rare malformation, and we have found 12 reported cases including our one case in the Japanese literatures. Moreover our case is the first one whose accessory esophagus were combined with an esophagobronchial fistula.

We experienced a successful repair of congenital esophago-bronchial fistula communicated between esophageal diverticulum and left main bronchus in adult case. The patient was a 60-year-old female. She had much wet cough on taking meals since 10 years ago. At the mass screening, a esophago-bronchial fistula was detected by upper GI series. Barium esophagography revealed a fistula between esophageal diverticulum and left main bronchus. The resection of diverticulum and fistula were undergone. In the operation, there exited no adhesion or inflammation around the fistula, therefore it was easy to isorate from the surrounding tissues. This case was categorized as Brainbridge type I esophago-bronchial fistula communicated to left main bronchus. Forty-six cases of congenital esophago-bronchial fistula with diverticulum were reported in Japan, but no cases which communicated with left main bronchus were reported. Then it is assumed that this is the first case in Japan.

Esophageal bypass operation was carried out for a patient with lung cancer who was not able to take oral feeding, due to esophageal stenosis and esophago-bronchial fistula. Stomach was used as a esophageal substitute, through antethoracal route. Abdominal esophago-jejunostomy was performed for drainage of esophago-bronchial fistula. Oral intake of foods was started from 11th postoperative day without major complication. And then, she was permitted to discharge only with a jejunostomal feeding tube. Recently the quality of life is emphasized, even in cases in which curativity of cancer cannot be expected. Surgery in such cases entails many risks and then, special care must be taken to determine the indication and procedure of this operation. In the case herein reported, such attention to detail resulted in survival for over one year.

A very rare case of congenital esophago-bronchial fistula in the adult is reported. Sixty-five years old, female. Complaining cough at drinking water and epigastric pain was diagnosed as esophago-bronchial fistula with esophageal diverticulum by Barium swallow and esophagoscopy. The resection of the fistula and diverticulum and the repair were carried out with smooth postoperative course. No evidence of inflammation along the fistula was demonstrated at surgery and microscopic findings of the resected material revealed the direct communication from the squamous epithelium to the cuboidal epithelium with underlying muscle layer in the wall. These results suggested this case the congenital esophago-bronchial fistula (Braimbridge type I).

A case of congenital esophagobronchial fistula in a 73-year-old woman was described. The patient had presented with repeated attacks of pulmonary infection from her childhood and had a several years history of recurrent cough after eating or drinking. Preoperative examinations including esophagogram by barium swallow revealed existence of a fistula between middle thoracic esophagus and right B6 bronchus. The fistula was recognized as Type II of Braimbridge and Keith's classification. The fistula was surgically removed with the atelectatic right lower lobe. Neither adhesion nor enlargement of lymph nodes was found in the surrounding tissues. Because the bronchial branch of vagus was found along the fistula, this lesion was strongly suggested of congenital origin. Histological observations of the resected fistula showed no chronic inflammatory changes, though muscular layers and transitional zone between squamous epithelium and bronchial epithelium were present. The differential diagnosis between the congenital and acquired types is sometimes very difficult. The existence of the bronchial branch of vagus along the fistula means that the fistula is a congenital type, definitely.

A 69 year-old man, who had undergone left pneumonectomy for squamous cell carcinoma of the lung 21 months ago, was admitted with a high temperature and chest pain. A diagnosis of empyema was made, and a chest tube was inserted for drainage. Bronchopleural fistula was not noted. Noticing that food was leaking through the drainage tube, a diagnosis of esophagopleural fistula was made radiologically. Surgery was done in October, 1987, after irrigating an empyema space for two months. The fistula was approximately 4 cm below the carina, and it was closed directly. The omentum was sutured around the closed site to reinforce and obliterate the empyema space. Furthermore, additional thoracoplasty was done because the cavity was too large to close only with the omentum. The postoperative course was uneventful. He was able to eat specially prepared foods within 4 weeks, and was discharged on the 60th day after the operation. This patient could possibly be the first case who had undergone an omental flap for the closure of a postpneumonectomy esophagopleural fistula.