Aortoenteric fistula following overlap esophagojejunal anastomosis using linear staplers for cancer of the esophagogastric junction: a case report

Abstract

BackgroundAortoenteric fistula (AEF), occasionally reported as a fatal complication after aortic or other vascular procedures, is a communication between the aorta and the digestive tract. AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy has not been reported previously. Herein, we report a case of AEF after laparoscopic proximal gastrectomy and transhiatal lower esophagectomy for cancer of the esophagogastric junction, in which linear staplers were used for overlap esophagojejunostomy.Case presentationA 66-year-old woman with advanced cancer of the esophagogastric junction underwent laparoscopic proximal gastrectomy and transhiatal lower esophagectomy with abdominal and lower mediastinal lymphadenectomy. Double tract reconstruction by the overlap method was performed. The patient was discharged from the hospital 10 days after surgery with a good postoperative course. However, she developed sudden-onset massive hematemesis and melena the day after discharge, resulting in death. Autopsy revealed that the stapled edge of the entry hole of the overlap esophagojejunostomy was in direct contact with the descending aorta. AEF was found at the esophagojejunostomy site.ConclusionsTo our knowledge, this is the first report of AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy. Although we could not definitively identify the cause of the AEF, it could be attributed to direct contact between the stapled edge and the bare thoracic aorta over a period of 10 days. To avoid direct contact with the aorta in esophagojejunostomy with linear staplers, all stapled edges should be covered by suturing and attention should be paid to the position of these edges.

Three‐stage approach for aortoesophageal fistula after Roux‐en‐Y esophagojejunostomy

“…Covering the esophagojejunal anastomosis with an omentum flap might be a considerable strategy. 5 This is a case of post-esophagojejunostomy AEF who survived more than 2 years. A three-stage hybrid strategy is safe and feasible to manage fatal secondary AEF, as follows:…”

“…3 By contrast, only two patients with post-esophagojejunostomy aortoesophageal fistula were reported. 4,5 The survivor, reported by Okita et al, 4 underwent primary closure and TEVAR to manage AEF, which occurred 24 days after esophagogastrectomy and alimentary reconstruction using a free jejunal graft. The other case, reported by Honda et al, 5 died 11 days after esophagogastrectomy, and the diagnosis of AEF was confirmed on autopsy.…”

“…4,5 The survivor, reported by Okita et al, 4 underwent primary closure and TEVAR to manage AEF, which occurred 24 days after esophagogastrectomy and alimentary reconstruction using a free jejunal graft. The other case, reported by Honda et al, 5 died 11 days after esophagogastrectomy, and the diagnosis of AEF was confirmed on autopsy. In our case, there was a 9-month interval between primary surgery and the development of AEF, and the patient also underwent adjuvant radiotherapy, which would deteriorate fistula formation and hinder subsequent surgical procedures.…”

“…However, direct contact between the staple line and thoracic aorta might cause AEF by sustained erosion. Covering the esophagojejunal anastomosis with an omentum flap might be a considerable strategy 5 …”

Treatment experience of delayed massive gastrointestinal bleeding caused by intra-abdominal arteriointestinal fistula in gastric cancer patients after radical gastrectomy

“…Several factors, including damage to the vasculature and perivascular nerve plexus in the vascular skeletonization process during lymphadenectomy, injury of the adventitia resulting from inappropriate use of the medical electric knife and ultrasound knife, and damage to the endarterium caused by ligation using inapposite sutures or crude clamping with vascular forceps, can result in chronic formation of pseudoaneurysm [3]. Furthermore, injury of the arterial wall resulting from postoperative persistent friction between the staple lines and bare arterial wall and perioperative radiotherapy has also been reported as a cause of pseudoaneurysm formation [9–11]. In general, rupture of the pseudoaneurysm mostly leads to intra-abdominal bleeding, and rupture into the gastrointestinal tract is rarely reported [5].…”