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Competing Interests: Disclosures None.

Background: The current study aimed to comprehensively analyze the clinical prognostic factors of malignant esophageal fistula (MEF). Furthermore, this study sought to establish and validate prognostic nomograms incorporating radiomics and clinical factors to predict overall survival and median survival after fistula for patients with MEF., Methods: The records of 76 patients with MEF were retrospectively analyzed. A stepwise Cox proportional hazards regression model was employed to screen independent prognostic factors and develop clinical nomograms. Radiomic features were extracted from prefistula CT images and post fistula CT images. Least absolute shrinkage and selection operator (LASSO) regression and Cox regression algorithm was used to filter radiomic features and avoid overfitting. Radiomic signature was a linear combination of optimal features and corresponding coefficients. The joint prognostic nomograms was constructed by radiomic signatures and clinical features. All models were validated by Harrell's concordance index (C-index), caliberation and bootstrap validation., Results: For overall survival, age, prealbumin, KPS and interval between diagnosis of esophageal cancer and fistula were identified as independent prognostic factors and incorporated into the clinical nomogram. Age, prealbumin, serum albumin, KPS and neutrophil proportion were selected for the clinical nomogram of post fistula survival. The C-index of overall survival nomogram was 0.719 (95% CI: 0.645-0.793) and that was 0.722 (95% CI: 0.653-0.791) in the post fistula survival nomogram. The radiomic signature developed by radiomic features of prefistula CT showed a significant correlation with both overall survival and post fistula survival. The C-index of joint nomogarm for overall survival and post fistula survival was 0.831 (95% CI: 0.757-0.905) and 0.77 (95% CI: 0.686-0.854), respectively. The calibration curve showed the joint nomograms outperformed the clinical ones., Conclusions: The study presents nomograms incorporating independent clinical risk factors and radiomic signature to predict the prognosis of MEF. This prognostic classification system has the potential to guide therapeutic decisions for patients with malignant esophageal fistulas., (© 2021 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Background: The literature regarding esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy (IMRT) for esophageal squamous cell carcinoma (ESCC) remains lacking. We aimed to investigate the risk factors of esophageal fistula among ESCC patients undergoing definitive concurrent chemoradiotherapy (CCRT) via IMRT technique., Methods: A total of 129 consecutive ESCC patients receiving definitive CCRT with IMRT between 2008 and 2018 were reviewed. The cumulative incidence of esophageal fistula and survival of patients were estimated by the Kaplan-Meier method and compared between groups by the log-rank test. The risk factors of esophageal fistula were determined with multivariate Cox proportional hazards regression analysis., Results: Median follow-up was 14.9 months (IQR, 7.0-28.8). Esophageal perforation was identified in 20 (15.5%) patients, resulting in esophago-pleural fistula in nine, esophago-tracheal fistula in seven, broncho-esophageal fistula in two, and aorto-esophageal fistula in two patients. The median interval from IMRT to the occurrence of esophageal fistula was 4.4 months (IQR, 3.3-10.1). Patients with esophageal fistula had an inferior median overall survival (10.0 vs. 17.2 months, p = 0.0096). T4 (HR, 3.776; 95% CI, 1.383-10.308; p = 0.010) and esophageal stenosis (HR, 2.601; 95% CI, 1.053-6.428; p = 0.038) at baseline were the independent risk factors for esophageal fistula. The cumulative incidence of esophageal fistula was higher in patients with T4 (p = 0.018) and pre-treatment esophageal stenosis (p = 0.045). There was a trend toward better survival after esophageal fistula among patients receiving repair or stenting for the fistula than those only undergoing conservative treatments (median survival, 5.9 vs. 0.9 months, p = 0.058)., Conclusions: T4 and esophageal stenosis at baseline independently increased the risk of esophageal fistula in ESCC treated by definitive CCRT with IMRT. There existed a trend toward improved survival after the fistula among patients receiving repair or stenting for esophageal perforation., Competing Interests: The authors have declared that no competing interests exist.

Background: Fistulous tracts within the thorax are best exemplified aorto-esophageal fistulas (AEFs), which are rare exsanguinations of the upper gastrointestinal tract. Most of them are diagnosed at autopsy., Aim: This is an autopsy-based study of fatal cases of AEFs gathered over a period of 20 years., Materials and Methods: Cases of AEFs were retrieved from the autopsy records of the cardiovascular pathology sub-specialty at a tertiary care center and were studied with reference to demographic details, modes of clinical presentation, and pathological features., Results: Ten cases of AEFs (10 males and 8 females, mean age of 46.9 years) were identified in a span of 20 years. A clinical diagnosis of AEF was made in only one patient, while the rest were identified at autopsy. All the patients had a bout of massive and fatal hematemesis. The fistulous connections, involving the middle-third of the esophagus, were caused by a fishbone, esophageal ulceration and aneurismal aortic diseases of varied etiology., Conclusions: AEFs are often missed or misdiagnosed. Early recognition of this rapidly fatal condition is essential as these fistulas require quick and aggressive management.

Purpose: Atrial fibrillation (AF) is the most common heart rhythm disorder in the world. Radiofrequency catheter ablation (RFCA) has become the preferred method of treatment for drug-refractory AF. One of the rare (< 0.2%) but deadly (≈ 80%) complications of RFCA is Atrioesophageal fistula (AEF). Although the exact pathophysiological events in developing AEF are not fully understood, one hypothesis is that the underlying cause may be thermal damage to the mucosa (the esophagus lumen)., Method: The present study reports on a computer model of RFCA in the posterior wall of the left atrium (LA) which is in close proximity to the esophagus. A novel systematic approach was taken by considering a range of anatomical variations (obtained from clinical data) to study the spatial and temporal temperature data when RF energy was applied to cause a threshold temperature of 50 °C in the mucosa. The model is also used to investigate the spatial and temporal changes in mucosal temperature that may affect the reliability of the readings from esophageal temperature monitoring devices if they are not positioned accurately., Results: The results suggest evidence of transmural esophageal lesions in all the anatomies except one, if the 50 °C temperature threshold is the only criteria used for identification of thermal damage. However, by taking into consideration the effect of time (temperature-time integral), only some anatomies were identified as being partially damaged. Investigating the temperature and the temperature gradient data during the ablation revealed that the increases in both the temperature and the temperature gradient were time, location and anatomy dependent. This finding may have significance in the design and development of next-generation temperature monitoring devices that will provide a temperature map rather than single point measurements., Conclusion: Studies such as the present work may provide more convenient platforms for investigating the effect of the many factors involved in the RF procedure and how they may link to the development of AEF.

Background and Aim: Fistula is one of the known complications of T4 esophageal cancer (T4-EC). The standard treatment for T4-EC is chemoradiotherapy, but detailed data about fistula resulting from chemoradiotherapy in this condition are limited. In particular, radiographic findings of T4-EC with fistula have not been reported. This study assessed the risk factors of fistula based on clinical information on patients with chemoradiotherapy for T4-EC., Methods: We retrospectively reviewed the clinical data of 59 T4-EC patients who had squamous cell carcinoma without any fistula before receiving definitive or palliative chemoradiotherapy., Results: A fistula was observed in 18 patients (31%) throughout their clinical course. The overall survival in the fistula group was significantly shorter than that in the non-fistula group (259 vs. 346 days; p = 0.0341). The axial tumor size on computed tomography (CT) was confirmed as an independent risk factor for esophageal fistula in multivariate analysis of stepwise methods [OR 1.226; 95% CI 1.109-1.411; p < 0.0001]. Twelve out of 14 patients with an axial tumor size of 50 mm or greater had developed a fistula., Conclusions: A large tumor size on the axial plane on CT is a risk factor for fistula formation.

Background and Aims: The development of esophagorespiratory fistula (ERF) in esophageal cancer (EC) is a devastating complication, leading to poor survival rates and low quality of life. Goal of this study was to identify risk factors leading to fistula formation in esophageal cancer., Methods: We identified 47 patients with malignant ERF formation in EC in a period of 10 years. Clinical characteristics were compared by univariable analysis to 47 randomly selected patients with EC, but without ERF. A case-control study was conducted for patients with squamous cell carcinoma (SCC) and ERF matching in a 1:2 fashion for primary tumor localization., Results: Identifiable risk factors in EC patients were histology of SCC (P-value < 0.001), former or current smoking status (P = 0.002) and primary tumor localization in the proximal esophagus (P < 0.001). The "hot spot" for ERF formation was tumor growth 20-25cm distal to dental arch. An additional risk factor in SCC patients was age. Patients with ERF formation in SCC were younger than patients without ERF (median 63 vs. 67 years, P = 0.02). No difference in the rate of fistula formation was seen between esophagectomy and definitive chemoradiation, but the latter developed ERF earlier in the course of the disease (237 vs. 596.5 days, P = 0.01)., Conclusion: Patients with proximal SCC of the esophagus and a smoking history, as well as young patients with SCC should be closely monitored for ERF formation.

Background: An esophagorespiratory fistula (ERF) is a fatal complication for patients with tracheobronchial invasion by esophageal cancer. We report the case of a long-term esophageal cancer survivor treated by esophageal bypass operation for ERF after chemoradiotherapy (CRT)., Case Report: A 44-year-old man was treated with definitive CRT (i.e. 66 Gy radiotherapy, chemotherapy with cisplatin, and 5-fluorouracil) for unresectable locally advanced esophageal cancer with massive invasion of the left main bronchus. Although a complete clinical response was obtained, the patient developed pneumonia due to an ERF. Esophageal bypass operation was performed for symptomatic relief. The patient's symptoms improved and oral ingestion became possible. No recurrence has been seen for 12 years., Conclusion: Esophageal bypass surgery can help in relieving symptoms and might be associated with long-term survival for esophageal cancer patients with ERF after good response to CRT. Thus, bypass surgery is a useful option in the treatment for esophageal cancer with ERF., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Oesophago-pericardial fistula following any electrophysiological procedure is a rare, and potentially, life-threatening condition. Initial presentation can easily be misdiagnosed, as symptoms vary and are not specific. Echocardiography is an invaluable tool to diagnose and rule out complications. We present the case of a 68-year-old patient who developed an oesophago-pericardial fistula complicated with purulent pericarditis, sepsis and cerebral air embolism. In conclusion, this case report encourages physicians to use strategies that may help with early diagnosis and lead to potential lifesaving interventions., (© Royal College of Physicians 2019. All rights reserved.)

Background and Objectives: The formation of a fistula between the gastrointestinal tract and cardiovascular system is a rare but devastating condition. Although clinical diagnosis is suspected, autopsy confirmation is rarely obtained. Advancement in the treatment of esophageal cancer could result in an increased risk of enterovascular fistula formation. We describe autopsy-proven series of enterovascular fistulas with particular focus on this complication developing as a consequence of esophageal cancer therapy. Methods: Cases of enterovascular fistulas were retrospectively identified in the institutional autopsy case records (1994-2017). Relevant clinical information and pathologic findings were reviewed. Results: Nine cases were identified. Seven out of 9 were related to malignancy, with 6/9 occurring in the setting of treated esophageal carcinoma. This esophageal cancer group was a unique set of patients (age median: 71 years) with male predominance (M:F-5:1) presenting with hematemesis as the main symptom. All patients had advanced disease at diagnosis and the complication generally occurred late after treatment (mean interval: 1.7 years). The fistula site was between the esophagus and variety of vascular structures. The most common etiology was tumor invasion (4/6). The diagnosis of enterovascular fistula was made postmortem in all cases. Conclusions: The development of enterovascular fistulas is a late complication of treated esophageal cancer. Tumor invasion, infection, and radiation response are the leading etiologies. Early recognition and aggressive treatment may salvage this highly morbid complication.

The mortality rate of aortic aneurysm/dissection is low in Japan. Two surgical procedures, the thoracic endovascular aortic repair (TEVAR) and the open stent-grafting have contributed much in survival of such aneurysmal patients. We encountered with two autopsy cases of death by aortic rupture with fistula formation after these procedures. Case 1 is an 85-year-old male who had the history of TEVAR for thoracic aorta aneurysm one and a half year before his death. His endovascular stent-graft was composed of a steel endoskeleton consisting of six Z-shape elements while at autopsy, one of the elements locating at the distal part was found inserted deep into the wall of descending aorta, causing aorto-esophageal fistula. Case 2 is an 88-year-old male who had the history of open stent-grafting for aortic aneurysm eight years ago. At autopsy, the stent-graft was found detached from aorta at its lesser curvature, causing gap formation between the aorta and the stent. Six Z-shaped stent elements, the parts of stent-graft, were found separated from descending aorta and located in the aneurism. Furthermore, three of the separated elements were found inserted deep in the aortic wall, causing aorto-pulmonary fistula. Since aorto-esophageal fistula formation after surgery for aortic aneurysm is very rare in TEVAR and there are no reported cases of death by aorto-pulmonary fistula in the open stent-grafting, these cases are reported here., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

A 76-year-old woman was admitted to the hospital four times from November 2007 to June 2009. In this complex case, the patient had silicosis complicated by broncholithiasis, oesophagobronchial fistulas, and relapsed tuberculosis. She had worked as a stone crusher for 3 years and was exposed to a large amount of quartz dust. Barium oesophagography, gastroesophageal endoscopy, and biopsy suggested oesophageal-related chronic inflammation and ulceration, which may have caused the repeated oesophagobronchial fistulas. Bronchoscopy revealed a free broncholithiasis in the left mainstem bronchus. The patient was admitted a fourth time because of silicotuberculosis relapse. After 9 months of antituberculosis treatment, the patient recovered and was still clinically well at the time of this writing.

Goal: The purpose of this study was to characterize outcomes of esophagorespiratory fistulas (ERF) by etiology and initial treatment strategy., Background: ERF is a morbid condition for which optimal treatment strategies and outcomes are still in evolution., Study: Medical records and images were reviewed for all patients diagnosed with ERF at Mayo Clinic in Rochester, MN, between September 1, 2001 and January 1, 2012. Fistulas were classified as malignant or benign. Treatment strategies were classified as surgical or nonsurgical (typically esophageal stent placement). Technical and clinical success, survival, and survival free of second intervention were assessed., Results: A total of 123 patients with acquired ERF were identified, of whom 65 (53%) were malignant and 58 (47%) benign. Initial treatment strategy was nonsurgical in 88 (72%) patients and surgical in 35 (28%); lower Charlson comorbidity scores were associated with increased likelihood of surgery. Technical and clinical success was seen in a majority of patients treated both surgically and nonsurgically. Patients with malignant ERF treated surgically survived longer than patients undergoing nonsurgical treatment (hazard ratio=5.6, P=0.005). In contrast, those with benign ERF had similar overall survival regardless of whether they received initial surgical or nonsurgical treatment; reintervention was more common in those who underwent nonsurgical treatment (hazard ratio=2.3, P=0.03)., Conclusions: We conclude that survival in malignant ERF is better with surgical intervention in selected patients. Surgical and nonsurgical techniques achieve similar survival in benign ERF, but reintervention is more common in those treated endoscopically.

Two patients with locally advanced squamous cell carcinoma of the mid-esophagus, with esophageal stents in situ, suffered sudden onset of massive hematemesis and hemodynamic instability due to an aortoesophageal fistula. Although their esophageal neoplasms were deemed inoperable and treatment was palliative, the bleeding was successfully stopped with an endovascular aortic stent-graft. They both remained stable with no septic or hemorrhagic complications, and survived for 14 and 16 weeks after the operation. We emphasize that even if esophageal tumors are locally advanced, emergency endovascular management of aortoesophageal fistula is worthwhile for prolongation of survival.

BACKGROUND Percutaneous catheter radiofrequency ablation (RFA) and cryoablation of the left atrium and pulmonary vein ostia have become successful therapeutic modalities in the management of atrial fibrillation. Atrio-esophageal fistula is a rare complication. Awareness of complication risk is imperative because without prompt diagnosis and urgent surgical intervention, the outcome is often fatal. We present 3 cases of atrio-esophageal fistula following percutaneous catheter radiofrequency ablation (RFA). CASE REPORT Case 1: A 72-year old white male presented 27 days after percutaneous RFA for atrial fibrillation with fever, altered mental status, and melena. Esophagogastroduodenoscopy (EGD) revealed a 1-cm defect in the mid-esophagus. Upon thoracotomy, severe hemorrhage ensued from a concomitant injury to the left atrium. Multiple attempts to repair the left atrial perforation were unsuccessful and the patient died. Case 2: A 71-year old white male presented 29 days after percutaneous RFA for atrial fibrillation with fever and tonic-clonic seizure. Recognition of possible atrio-esophageal fistula was considered and confirmed on thoracotomy. Surgical fixation of the left atria and esophagus were performed. The patient survived and was discharged to a skilled care facility. Case 3: A 75-year old white male presented 24 days after percutaneous RFA for atrial fibrillation with chest pain. An echocardiogram revealed a large pericardial effusion and pericardiocentesis was performed. Despite aggressive measures, the patient died. The autopsy demonstrated a communicating esophageal fistula with the right pulmonary vein. CONCLUSIONS Clinicians tending to patients who have recently undergone atrial ablation need to be aware of atrio-esophageal fistula as a rare but highly fatal complication.

The ingestion of extraneous substances is quite common in clinical practice; it usually befalls in the pediatric age, mostly between 6 months and 6 years. In most cases, complications do not emerge, and the prognosis is considered favorable. However, when a case of battery ingestion occurs, serious adverse events may develop. The ingestion of these components is a potential life-threatening event for children.In this article, we report the case of an 18-month-old child who died from hemorrhagic shock due to an aortoesophageal fistula caused by a 20 mm lithium button battery lodged in the esophagus.The child presented vomiting blood, and laboratory results revealed a severe anemization, which later led to death.The autopsy showed a coin battery located in the middle third of the esophagus as well as a transmural erosion of the esophageal wall with fistulization into the aortic wall. The histological examination revealed a severe necrosis of the esophageal and aortic walls in line with the junction between the aortic arch and the descending part.

Background Fistulas after esophagectomy are a significant cause of morbidity and mortality. Several endoscopic treatments have been attempted, with varying success. An experimental model that could validate new approaches such as cellular therapies is highly desirable. The aim of this study was to create a chronic esophageal enterocutaneous fistula model in order to study future experimental treatment options. Methods Eight pigs (six 35-kg young German and two 50-kg adult Yucatan pigs) were used. Through a left and right cervicotomy, under endoscopic view, 1 (group A, n = 6) or 2 (group B, n = 7) plastic catheters were introduced into the esophagus 30 cm from the dental arches bilaterally and left in place for 1 month. Radiologic and endoscopic fistula tract evaluations were performed at postoperative day (POD; 30) and at sacrifice (POD 45). Results Three fistulas were excluded from the study because of early (POD 5) dislodgment of the catheter, with complete fistula closure. At catheter removal (POD 30), the external orifice was larger in group B (5.2 ± 1.1 mm vs 2.6 ± 0.4 mm) with more severe inflammation (72% vs 33%). At POD 45, the external orifice was closed in all fistulas in group A and in 1/7 in group B. At necropsy, the fistula tract was still present in all animals. Yucatan pigs showed more complex tracts, with a high level of necrosis and substantial fibrotic infiltration. Conclusions In this article, we show a reproducible, safe, and effective technique to create an esophagocutaneous fistula model in a large experimental animal., (© The Author(s) 2016.)

Background and Goals: Using a self-expandable metallic stent (SEMS) in the cervical esophagus is controversial due to an increased risk of complications. Here we assessed a new type of SEMS purpose-designed for the cervical esophagus area., Study: Patients with malignant or benign stenosis within 4 cm distance of the upper esophageal sphincter who underwent placement of a SEMS with a shorter proximal head (Niti-S Esophageal Covered Stent-Cervical-type, NSECSC), were included. Main outcome measures were the functional outcome, tolerance, complications, recurrent dysphagia, and survival., Results: About 37 patients had an NSECSC placed between April 2008 and June 2013 for esophageal stenosis (malignant=20, benign=17), 5 with associated tracheoesophageal fistula. The mean stenosis-upper esophageal sphincter distance was 1.86±1.27 cm. The median follow-up was 150 days. Dysphagia improved in 27/37 cases (73%). Short-term and long-term tolerance without needing stent removal was 92% and 82%, respectively. The complication rate was 59% (22/37): 32% (n=14) major complications [fistula (3), perforation (3), aspiration pneumonia (5), laryngeal dyspnea (2), and bleeding (1)], and 27% (n=10) minor complications [pain (7) or dysphonia (3)]. A multivariate analysis confirmed a higher risk of major complications in cases of benign stenosis (odds ratio=5.2; 95% confidence interval, 1.05-25.90; P=0.04). Recurrent dysphagia occurred in 15 patients (obstruction=7, migration=8)., Conclusions: The NSECSC does not appear less morbid than standard SEMS in the cervical esophageal area, but could be useful in malignant indications as it is well-tolerated and offers effective palliation of the dysphagia. However, this device should not be used in benign cervical esophageal strictures or fistulas.

Cardioesophageal fistulas (CEFs) are uncommon but life-threatening complications of radiofrequency (RF) catheter ablation of atrial fibrillation (AF). They are usually, but not exclusively, related to ablation of the left atrial posterior wall. We report a case of a 73-year-old man that presented with CEF following RF ablation in the coronary sinus, highlighting the importance of esophageal temperature monitoring whenever ablating in the posterior heart., (© 2015 Wiley Periodicals, Inc.)

The study presents an exceptionally rare case of an esophago-left atrial fistula, which was diagnosed during a forensic post-mortem examination. Due to complex nature of the disease and many attempts to cure the patient, the authors did not manage to identify the aetiology of the fistula. It was only implied that the fistula might have been a distant complication of intraoperative endocardial ablation or it might have appeared as a consequence of perforation of the esophageal wall or left atrial wall of the enlarged heart with the end of an intubation tube or nasogastric tube., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

The development of a fistula between the tracheobronchial tree and oesophagus due to nonmalignant causes is uncommon. Division of the fistula with muscle flap interposition eliminates contact between the tracheobronchial segment and the oesophagus, theoretically decreasing the chance of recurrence as well as providing a robust blood supply to aid in healing. The split latissimus dorsi muscle flap is a well-suited flap for such repairs because of the ability to simultaneously cover two separate apertures (tracheobronchial and oesophageal). The authors describe the split latissimus dorsi muscle flap with step-by-step technique for repair of intrathoracic aerodigestive fistulas., (Copyright © 2015. Published by Elsevier B.V.)

Tuberculosis remains a serious public health problem worldwide, especially in Korea. Although tuberculosis is generally considered a non-fatal chronic disease, deaths have occurred. In this case study, a 68-year-old man was admitted to the hospital with dyspepsia, vomiting, and abdominal pain. Nine hours later, he suffered severe hematemesis and died despite cardiopulmonary resuscitation. A medico-legal autopsy was performed and an external examination revealed no external injuries. However, an internal examination revealed an aortoesophageal fistula and a large amount of blood in the stomach. A histologic examination confirmed tuberculous mediastinitis with disseminated tuberculosis involving multiple organs, including the heart, lungs, liver, kidneys, and spleen. Both an aortoesophageal fistula and sudden death due to tuberculosis infection are rare. This paper reports the case of a fatal aortoesophageal fistula associated with disseminated tuberculosis.

The layout of the porcine atriopulmonary junction and immediately adjacent structures was investigated by gross anatomical and vascular corrosion casting studies to meet the need for more in-depth anatomical insights when using the pig as an animal model in the development of innovative approaches for surgical cardiac ablation in man. The veins from the right cranial and middle lung lobes drain through a common ostium in the left atrium, whereas a second ostium receives the blood returning from all other lung lobes, although limited variation to this pattern was observed. Surrounding anatomical structures that are most vulnerable to ablation damage as reported in man are located at a safer distance from the pulmonary veins in pigs, yet a certain locations, comparable risks are to be considered. Additionally, it was histologically confirmed that myocardial sleeves extend to over a centimetre in the wall of the pulmonary veins., (© 2013 Blackwell Verlag GmbH.)

Traumatic pseudoaneurysms are relatively frequently mentioned in textbooks of pathology and forensic medicine but their incidence in pathological reports is seldom documented. Our described case presented a patient who suffered from chronic alcoholism and who was repeatedly hospitalised because of various injuries including epidural and subdural hematomas. We present a case of a 69-year-old man who was hospitalised after nonspecific blunt chest injury with chest pain and dysphagia. By computed tomography the traumatic pseudoaneurysm of the descendent thoracic aorta was diagnosed pressing the oesophageal wall which was solved by implantation of aortal stent graft (TEVAR - thoracic endovascular aortic/aneurysm repair). Since after the implantation there was no blood leak, no progression of the lesion, he was soon discharged from hospital. The patient was hospitalised again after two months for newly developed haemoptysis. On suspicion of bleeding from aortal arch a carotid-carotid bypass from right to left side was performed and then re-TEVAR was implanted proximally to the first one. The man died two days following the implantation after a massive bleeding from oesophagus due to aortoesophageal fistula. The presented case deals with the etiology of the development of pseudoaneurysms, histomorphological picture of pseudoaneurysm resembling not only an isolated thoracic aortitis but slightly also the Takayashu disease. We suppose that in this case the most probable cause of necrosis and perforation of aortal wall was a decubital necrosis caused by stent graft which led to the fatal aortoesophageal necrosis. Aortoesophageal fistula belongs to the most common lethal complications of the TEVAR.

Atrial fibrillation (AF) is associated with significant morbidity and mortality. Hemodynamic compromise and formation of thrombi within the fibrillating atrium or atrial appendage can occur. Surgical treatment aims to eliminate dysrhythmia-triggering foci in the pulmonary veins and posterior left atrium by radiofrequency ablation techniques using ohmic heat. As medical treatment may be ineffective, radiofrequency catheter ablation is increasingly being used by interventional cardiac electrophysiologists for AF. Serious complications have been observed among patients who have undergone radiofrequency ablation, atrioesophageal fistula being a very rare example. This case describes a 43-year-old man who died after the development of an atrioesophageal fistula following radiofrequency ablation of the left atrium and pulmonary veins for treatment of AF., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aortoesophageal fistula (AEF) is highly lethal. A 74-year-old man presented with hematemesis and consciousness loss. He had a long-term history of hypertension and gout. Computed tomography revealed an aneurysm of the distal descending thoracic aorta, which was treated by insertion of an aortic stent graft. After 24 days of stenting, endoscopic examination revealed an AEF. After 6 months of stenting, he died owing to mediastinitis. On autopsy, macroscopically, we found a 4 × 2.5-cm, oval, well-circumscribed AEF. We identified squamous epithelium in the area surrounding the AEF that covered the thoracic aorta inner cavity. Immunohistochemical analysis revealed that the squamous epithelium in the thoracic aorta was positive for p63 and 34βE12. In conclusion, we encountered a long-term AEF case with aortic squamous metaplasia. To the best of our knowledge, human aortic metaplasia has never been reported. In the present case, aortic squamous metaplasia retained continuity with the esophageal squamous epithelium; therefore, the migration of the squamous epithelium through the AEF may have been induced by aortic erosion., (© 2014 The Authors. Pathology International © 2014 Japanese Society of Pathology and Wiley Publishing Asia Pty Ltd.)

Esophageal foreign body ingestion is especially frequent in childhood and may cause fatal complications in case of late diagnosis and delayed treatment. We present a case of 2-year old girl who was admitted to emergency department with massive bleeding. However, she died due to an unrecognized foreign body resulted an aorto-esophageal fistula. At autopsy an aorto-esophageal fistula was detected by gross examination. Tissue samples were obtained from the organs and fistula region. In histopathological examination, a calcified body with multinucleated giant cell and surrounding granulation tissue was detected at the bleeding site. An ulcerated fistula tract ran from the intima to the adventitia, passing through layers of esophageal wall was also noticed. The mortality rate for foreign body ingestion is less than 1%, except in cases of perforation. Therefore the presented case is among rare examples of fatal foreign body ingestions., (Copyright © 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Delayed presentation of coarctation of the aorta can be associated with severe complications. A challenging case of aortoenteric fistula secondary to an aneurysm from coartation of the aorta presented with massive gastrointestinal hemorrhage. The clinical management of this patient and a review of the literature are presented.

We describe a rare case of aorto-oesophageal fistula and aortic pseudoaneurysm in a middle-aged man, who presented with chest pain and haematemesis 1 week after swallowing a fish bone. Oesophagogastroduodenoscopy and computed tomographic angiography findings were consistent with oesophageal perforation, proximal descending aortic pseudoaneurysm, and aorto-oesophageal fistula. Thoracic endovascular aortic repair was performed. The patient died from severe mediastinal sepsis. Early surgical intervention and broad-spectrum antibiotic therapy are crucial in preventing life-threatening mediastinal infection.

Objective: An aorto-oesophageal fistula is a rare clinical entity, leading to life-threatening gastrointestinal bleeding. Thoracic aortic aneurysms are the most common cause of aorto-oesophageal fistulae; further causes involve foreign body ingestion, trauma (in most cases iatrogenic), carcinoma or, very rarely, aortitis tuberculotica., Methods: Due to its rarity, there are no large multicentre studies present to evaluate the efficacy of different therapeutic management options. Since it is associated with significant morbidity and mortality, we give a short summary of various treatment approaches performed in our clinical practice in the past three years. The most straightforward therapeutic option may be an endovascular aortic repair and subtotal oesophageal resection followed by gastro-oesophageal reconstruction, but other alternative treatment possibilities are also present, although with probable higher morbidity., Conclusions: Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.

Aorto-oesophageal fistula refers to a rarely encountered communication between the aorta and the oesophagus that results in massive and lethal haemorrhage into the upper gastrointestinal tract. Although the time between the initial haemorrhage and the terminal event may be days, a clinical diagnosis may not be established by the time of autopsy. A fistulous tract develops between the aorta and the oesophagus most commonly due to expansion of a thoracic aortic aneurysm or from an ingested foreign body. Less common causes include infiltrating neoplasms, oesophageal ulceration, vascular rings and iatrogenic lesions. Three cases are presented to illustrate the features of such cases due to aortic dissection, bronchial carcinoma and tuberculosis. Cases should be suspected if there has been a history of midthoracic pain or dysphagia, a 'herald' haemorrhage and then massive fatal haematemesis with bright red blood. Careful dissection at autopsy is required to demonstrate the site of the fistulous tract., (Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Esophageal bypass surgery using a gastric tube prior to definitive chemoradiotherapy in preparation for the formation of esophago-tracheal or bronchial fistula is a possible strategy for esophageal cancer invading the airway. This report presents the case of a patient with esophageal cancer involving the left main bronchus who underwent esophageal bypass followed by definitive chemoradiotherapy and who has achieved long-term survival without deterioration of his quality of life, in spite of the development of a malignant esophago-bronchial fistula.

Aortoesophageal fistula (AEF) formation nearly always results in catastrophic consequences. As a result of its development being extremely rare, many may never consider it in their differential. Although prognosis is extremely grim, early diagnosis and intervention is considered the optimal means to enhance one's prognosis. We present a case of AEF formation secondary to a Stanford B aortic dissection, along with a review of literature and terminology involved in describing such pathology.

Arterioesophageal fistula is a rare cause of upper gastrointestinal tract bleeding. Arterioesophageal fistula and haematemesis are rare in poisoning, especially in noncorrosive poisoning. An arterioesophageal fistula can occur in patients with retroesophageal subclavian artery. This is usually associated with prolonged presence of nasogastric tube.