Total surgical repair for secondary aortoesophageal fistula: two case reports

[Aortoesophageal fistula-A rare differential diagnosis of upper gastrointestinal bleeding]

Approximately 1% of all patients are admitted to an emergency room for upper gastrointestinal hemorrhage. Differential diagnostics reveal an aortoesophageal fistula (AEF) as the cause of the bleeding in very few cases. Despite increasing means of diagnostics and treatment, mortality is high in patients with AEF even under maximum medical care. These are often fulminant situations with fatal outcome for the patient. We report a case that supports this observation described from previous cases and give a closer look at this rare emergency situation. A 54-year-old patient was taken to a maximum care hospital with the clinical diagnosis of upper gastrointestinal bleeding after receiving emergency medical treatment. The source of bleeding was quickly identified as an AEF following lobectomy for bronchial cancer. Despite maximum interventional intensive treatment, the patient died a few hours after hospital admission in hemorrhagic shock due to fulminant hemorrhage from the fistula.

Risk Factors for Mortality in Patients with Aortoesophageal Fistula Related to Aortic Lesions

Objective

Aortoesophageal fistula (AEF) related to aortic aneurysm and dissection is an uncommon but life-threatening condition. We performed a systematic review of risk factors for mortality and factors associated with the prognosis of AEF.

Methods

A systematic search of the PubMed, Embase, and Cochrane Library databases was performed. Clinical characteristics, diagnostic methods, and treatments were assessed in terms of their ability to predict mortality.

Results

The systematic review identified 184 eligible articles including 219 patients with AEF. Multivariable Cox regression revealed positive correlations of hemorrhagic shock (hazard ratio (HR): 1.824, 95% CI: 1.217-2.735, P = 0.004), sepsis (HR: 1.714, 95% CI: 1.112-2.641, P = 0.015), multiorgan failure (HR: 3.060, 95% CI: 1.470-6.368, P = 0.003), and conservative treatment (HR: 5.257, 95% CI: 3.405-8.116, P < 0.001) with mortality and a negative correlation between combination therapy (aortic graft replacement and esophagectomy) and mortality (HR: 0.319, 95% CI: 0.125-0.813, P = 0.017). Kaplan–Meier survival analysis showed that the 1-year cumulative survival rate was 42.5 ± 3.8%. The overall fistula-related mortality rate was 47.0% (103/219). The most common causes of death were bleeding (54.9%) and infection (29.2%).

Conclusions

We found that hemorrhagic shock, sepsis, and multiorgan failure were risk factors for death in patients with AEF. Additionally, conservative treatment was associated with a higher rate of mortality, while combined aortic graft replacement and esophagectomy improved the prognosis.