RESULTS
Patient characteristics, management strategies, and treatment outcomes are summarized in Table 1. The mean age was 67 years (range, 41–78 years); five patients were male (83%). Four patients had undergone TEVAR, two for thoracic aortic aneurysm, and two for chronic aortic dissection. Three (75%) of the four post-TEVAR cases underwent emergency TEVAR for impending rupture of the thoracic aorta. Two patients had undergone total arch replacement, one for thoracic aortic aneurysm, and one for chronic aortic dissection. There were no patients who had previously undergone esophageal surgery.
All six patients presented with fever and complained of general fatigue. The causative bacteria were detected in five patients (83%);Streptococcus in three and Staphylococcus in two. Antibiotics were administered preoperatively and continued for at least 4 weeks following surgery. Gallium scintigraphy successfully detected the primary origin of sepsis in four patients (Figure 1e, 1f, 1g). Computed tomography was performed in all patients and additional endoscopy was performed in five (83%) patients to confirm the diagnosis. In three patients, computed tomography demonstrated severe infection with air bubbles between the aorta and esophagus (Figure 1a, 1b). In two patients, endoscopy clearly identified the fistulas (Figure 1c, 1d).
Surgical indication and strategy were decided considering each patients’ frailty and infection severity. Two patients who had undergone total arch replacement underwent definitive open surgical repair (Figure 2a); of the patients who had undergone TEVAR previously, two underwent TEVAR alone and two underwent combined repair with TEVAR and open surgery (Figure 2b). In the two patients who had open surgical repair (Figure 2a), a longer period until treatment completion was necessary (229 days and 209 days), but they were discharged without complications. The patients who underwent TEVAR alone had required urgent surgery to control bleeding, and TEVAR was, therefore, performed without esophagectomy or reconstruction of the aorta. These patients were discharged without major complications shortly following surgery, in 28 and 86 days. In one of the two patients who underwent combined repair, the aorta could not be resected due to severe adhesions, and esophageal reconstruction could not be completed following esophagectomy due to the severely deteriorated state of the patient. This patient died of an aortobronchial fistula during hospitalization. In the other patient, esophageal repair was performed without esophagectomy. An additional extra-anatomical bypass from the ascending aorta to the abdominal aorta bypass with closure of the aortic stump was performed due to severe adhesions (Figure 2b). This patient died of sepsis during hospitalization.
Overall, in-hospital mortality occurred in two (33%) of the total 6 patients, who underwent combined repair. The condition of both these patients was too deteriorated to undergo definitive repair of the aorta and esophagus, and they were subsequently hospitalized for a long period (118 days and 265 days). Furthermore, they had severe adhesions between the aorta and esophagus. Late mortality occurred in two (50%) of the remained four patients. One patient who underwent TEVAR alone died of rupture of the remaining thoracic aortic aneurysm 6 months following surgery, and one patient who underwent surgical open repair died of pneumonia 1 year following surgery.