Aortoesophageal Fistula and Aortic Pseudoaneurysm Induced by Swallowed Fish Bone: A Report of Two Cases

Multi-modality management of defects in the gastrointestinal tract: Where the endoscope meets the scalpel: Endoscopic vacuum therapy in the upper gastrointestinal tract

BACKGROUND

Transmural defects in the upper gastrointestinal (GI) tract, such as anastomotic leakage and oesophageal perforations, are associated with significant morbidity and mortality risks. Endoscopic vacuum therapy (EVT) is an efficient and safe treatment option for these patients. With the growing use of EVT in the upper GI tract, it is important to share expertise on the topic.

AIM

This review explores the emerging role of endoscopic vacuum therapy (EVT) as treatment for transmural defects in the upper GI tract. An overview of the mechanism and procedures, outcomes in current literature and challenges of implementation and application are discussed.

CONCLUSION

EVT exhibits great efficacy and safety for the treatment of transmural defects in the upper GI tract. Current use of EVT is mostly experience-based, emphasizing the importance of sharing expertise and performing research to unlock its full potential.

Teach a man to fillet: gastrointestinal and extra-gastrointestinal complications related to fish bone ingestion

Accidental ingestion of fish bone is a common occurrence in populations that consume unfilleted fish. Although most ingested foreign bodies pass through the gastrointestinal tract uneventfully within a week, less than 1% of patients unfortunately develop gastrointestinal perforation. Occasionally, some patients who are unaware of an episode of fish bone ingestion may present sub-acutely with symptoms mimicking inflammatory conditions or pyrexia of unknown origin. Computed tomography (CT) is the definitive imaging modality in the diagnosis of fish bone foreign body and its complications. This pictorial essay aims to illustrate the various complications related to fish bone ingestion, broadly divided into gastrointestinal related complications and extra-gastrointestinal complications related to migration of fish bone. Radiologists should be familiar with the myriad of possible complications, and take heed that a relevant history of fish bone ingestion is often absent.

The life-saving emergency thoracic endovascular aorta repair management on suspected aortoesophageal foreign body injury

BACKGROUND

Fatal aortic rupture caused by esophageal foreign body (EFB), is associated with a high mortality, but can be prevented by thoracic endovascular aorta repair (TEVAR) that performed increasingly as technology improves. This study aims to investigate the cause, management and prognosis of suspected penetrating aortoesophageal foreign body injury.

METHODS

Twelve cases who met the criteria were enrolled in this study. The demographic and clinical data were reviewed for evaluating the characteristics of EFB.

RESULTS

Among 12 cases enrolled, 7 were males and 5 were females, with an age 27-86 years. The distance of EFB from aorta (DFA) of 7 cases were less than or equal to 0 mm, 5 cases were 0-2 mm. Eleven cases were managed with TEVAR, only one case was with open surgery standby but finally treated by flexible endoscopy (FE) successfully, without TEVAR. In group with TEVAR, EFB of 7 cases were successfully removed by rigid endoscopy (RE), and one of them was failed at the first RE treatment. EFB of 2 cases were successfully removed by open surgery with TEVAR, and other 9 cases were managed by endoscopies with TEVAR. The mean length of stay of hospitalization (LOS) and length of ICU stay of patients treated by open surgery with TEVAR (18.50±2.12 days and 5.50±0.71 days) was significantly longer than those of patients treated by endoscopy with TEVAR (7.00±2.74 days and 1.33±1.12 days, P<0.001 and P=0.001, respectively). Five cases had severe complications.

CONCLUSION

Rational application of TEVAR can be a life-saving management for aortoesophageal foreign body injury, and jointed with endoscopy is safe and effective with a shorter length of ICU or total hospital stay.

Aortoesophageal fistula: review of trends in the last decade

We reviewed articles on aortoesophageal fistula (AEF) published between January, 2009 and December, 2018. Postoperative aortic disease was the most common cause of AEF, followed by primary aortic aneurysm, bone ingestion, and thoracic cancer. Thoracic endovascular aortic repair (TEVAR) was the most common initial therapy for primary aortic disease, rather than graft replacement. Secondary AEF developed between 1 and 268 months, and between 1 and 11 months after the initial therapy for aortic disease and thoracic cancer, respectively. TEVAR trended to be preferred over surgery for aortic lesions because of its minimal invasiveness and certified hemostasis. In contrast, esophagectomy was preferred for esophageal lesions to remove the infectious source. A combination of surgery for the aorta (TEVAR, graft replacement or repair) and esophagus (esophagectomy, esophageal stent or repair) was usually adopted. Each graft replacement or esophagectomy was associated with a favorable prognosis for aortic or esophageal surgery, and the combination of graft replacement and esophagectomy generally improved the prognosis remarkably. Antibiotic therapy was given to 65 patients, with 20 receiving multiple antibiotics aimed at strong effects and the type of antibiotic described as broad-spectrum in 29 patients. Meropenem, vancomycin, and fluconazole were the most popular antibiotics used to prevent graft or stent infection. In conclusion, graft replacement and esophagectomy can achieve a favorable prognosis for patients with AEF, but strong, broad-spectrum antibiotic therapy might be required to prevent sepsis after surgery.

An aorto-oesophageal fistula treated with endovascular aortic repair: the fate of untreated oesophageal lesion on endoscopic follow-up

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.

Clinical criteria for CT scan evaluation of upper digestive tract fishbone

OBJECTIVES

To establish clinical criteria for performing computed tomography scan for suspected upper digestive tract fishbone.

METHODS

This is a prospective study of all adult patients referred to the otolaryngology emergency department at our medical center for suspected fishbone in the upper digestive tract after no fishbone was seen on physical examination. The patients were divided into two groups: 1) The first was a high clinical suspicion group, which included patients with at least one of the following criteria: drooling, accumulation of saliva in the sinus piriformis, fever, referral 24 hours after the ingestion with worsening/continuing symptoms, and readmission. These patients underwent nonenhanced CT scan (NECT) of the neck. 2) The second was a low clinical suspicion group, which included patients discharged with no NECT performed. These patients were followed at 1 week and 3 months.

RESULTS

One hundred and fourteen patients were included in the study; the median age was 41 years. Half of the patients arrived at the emergency department within 7 hours. There were no false negatives. The negative predictive value and sensitivity were 100%. Positive predictive value and specificity were 28.5% and 65%, respectively. Referral to the emergency department 24 hours after the ingestion with continuing symptoms had the highest false positive rate.

CONCLUSIONS

Our clinical criteria score for excluding foreign body fishbone in the upper aerodigestive tract was established. According to this score, a NECT can be spared in about 75% of all cases, thus reducing unnecessary ionizing radiation, stay at the emergency department, and costs with a very high NPV of almost 99%.

LEVEL OF EVIDENCE

4. Laryngoscope, 2467-2472, 2018.

Use of the blue cotton screen method with endoscopy to detect occult esophageal foreign bodies

More than 20,000 cases of upper gastrointestinal foreign bodies (FBs) have been reported in the last 5 years in China. Early detection and treatment is vital in these patients. Differential diagnosis of esophageal injury and occult esophageal foreign bodies is challenging, particularly in the case of non-radio-opaque foreign bodies. A diagnostic technique with high accuracy and low risk is needed for clinical practice. We describe successful use of the "blue cotton screen method" to detect esophageal foreign bodies in 2 patients. The advantages and disadvantages of various diagnostic modalities in the management of patients with foreign body ingestion are presented. This technique is safer and more effective than traditional methods for foreign body impaction in the esophageal cavity. It could be applied for screening and in the differential diagnosis of esophageal injury and FBs in the esophageal lumen.

Aortic Pseudoaneurysm Secondary to Mediastinitis due to Esophageal Perforation

Esophageal perforation is a condition associated with high morbidity and mortality rates; it requires early diagnosis and treatment. The most common complication of esophageal rupture is mediastinitis. There are several case reports in the literature of mediastinitis secondary to esophageal perforation and development of aortic pseudoaneurysm as a complication. We report the case of a patient with an 8-day history of esophageal perforation due to foreign body (fishbone) with mediastinitis and aortic pseudoaneurysm. The diagnosis was made using Computed Tomography (CT) with intravenous and oral water-soluble contrast material. An esophagogastroduodenoscopy did not detect the perforation.

Management of an ingested fish bone in the lung using video-assist thoracic surgery: a case report

We report a case of lung abscess caused by an ingested fish bone that was successfully treated by minimally invasive surgery. Although cases of ingested foreign body abscess are well reported, lung abscess caused by ingested fish bone is extremely rare. To date, less than 10 similar cases have been reported in the literature. To the best of our knowledge, the case presented in this case report is the first report of this kind that was successfully treated by video-assist thoracic surgery (VATS). A 47-year-old man was admitted to department of thoracic surgery with the complaint of continues dry cough and fever. The patient accidentally swallowed a long sharp-blade-shaped fish bone 20 days before, which perforated the upper thoracic esophagus on the right and embedded in the right upper lobe.The diagnosis was verified by computed tomography scan and a video-assist thoracic surgery procedure was successfully performed to treat the patient. The patient survived the esophageal perforation fortunately without involvement of great vessel injury and probable mediastinitis. This report may provide additional experience on lung abscess caused by ingested fish bones. However, it is also important to educate the public of the risks of trying to force an ingested object down into the stomach.

Endovascular treatment of a left subclavian pseudoaneurysm induced by ingestion of a foreign body

Subclavian artery-esophageal fistula is a life-threatening entity. It usually occurs in cases of an aberrant right subclavian artery. A fistula between a non-aberrant subclavian artery and esophagus is extremely rare and difficult to diagnose. It is generally due to ingestion of a foreign body and it is often lethal. We present a case of subclavian artery-esophageal fistula complicated by mediastinitis in a 45-year-old man. The fistula, induced by ingestion of a fish bone, was successfully treated by endovascular stent grafting and left thoracotomy.

[Aortic pseudoaneurysm as a complication of oesophageal perforation caused by a fish bone]

We describe the case of a 41 year-old female patient with acute thoracic and epigastric pain associated with dysphagia. Due to the acute onset and the intensity of symptoms an urgent gastroscopy was requested. This was delayed and only performed when further serious complications appeared. This showed an oesophageal perforation due to ingestion of a fish bone, and an aortic pseudoaneurysm. Early determination of the cause and the extraction of fish bone would have avoided the subsequent worsening and long term stay in the hospital. Special tests limitations often delay diagnosis with severe consequences for the patients.