Endovascular stent graft repair of aortogastric fistula caused by peptic ulcer after esophagectomy

Abstract

Rationale:Aortogastric fistula (AGF) is a rare but devastating clinical complication after esophagectomy. In a recent report, nearly all AGF patients died of massive hemorrhage or aspiration of massive hematemesis. Therefore, timely appropriate treatment of AGF remains a challenge.Herein, we report a case of AGF that resulted from peptic ulceration after esophagectomy and was successfully treated with endovascular stent graft placement.Patient concerns:A 59-year-old man had undergone video-assisted thoracoscopic esophagectomy for squamous cell carcinoma and esophageal reconstruction using a gastric tube 14 months previously. He suddenly experienced massive hematemesis and unstable circulatory dynamics, Infusion was performed to treat critical hemorrhagic shock but was ineffective. We informed the patient and his family members of the situation, and once written informed consent to treatment was provided, we rushed him to the operating room.Diagnoses:Contrast medium permeated into the gastric cavity through a fistula between the abdominal aorta and gastric tube at the 11th thoracic level, Based on this, we made a diagnosis of AGF resulting from a peptic ulcer, and this diagnosis was further confirmed by high pressure angiography combined with computed tomography (CT) imaging.Interventions:An endovascular stent graft was placed under the guidance of digital subtraction angiography and followed by antibiotic therapy to prevent infection and proton pump inhibitor therapy to inhibit gastric acid secretion.Outcomes:The patient recovered uneventfully after the procedure. Four months after surgery, the patient died of organ failure caused by retroperitoneal lymph node metastasis and multiple intrahepatic metastases, with no postoperative bleeding linked to the endovascular stent graft repair.Lessons:Our case supports the notion that endovascular stent graft repair is a feasible alternative in treatment of AGF with several advantages in addition to surgical intervention, although more such cases should be collected and analyzed in the future to corroborate our observations.

Primary Aortogastric Fistula Caused by Ulcerated Gastric Carcinoma: A Rare Cause of Sudden Death

“…AGF is a very rare condition that commonly results in rapid exsanguination and has a high mortality rate (6,8). It is a pathologic connection between the aorta and stomach (5).…”

“…Primary AGF is a rare but life-threatening clinical entity, due mostly to foreign bodies, penetration by advanced esophageal carcinoma, esophageal hiatal hernia, pancreatitis, and peptic ulcer etiologies. Secondary AGF represents a fatal complication after an esophagectomy and intrathoracic esophagogastric anastomosis (3)(4)(5)(6)(7). Here, we describe a patient presenting with fatal hematemesis due to a primary AGF caused by ulcerated intrathoracic gastric carcinoma occurring 23 years after esophagectomy for esophageal carcinoma.…”