title: Outcomes of a staged surgical treatment strategy for aortoesophageal fistula.
abstract: BACKGROUND
  Evolution of thoracic endovascular aortic repair (TEVAR) appears to have influenced the pathogenesis and treatment strategy for aortoesophageal fistula (AEF). The purposes of this study are to evaluate our current surgical strategy for AEF and to provide insight to further improve the prognosis of such a devastating condition.
  
  
  RESULTS
  Between 2005 and 2013, we retrospectively reviewed the clinical charts of 10 patients requiring surgical treatment for AEF in Tohoku University Hospital. Four cases were primary and 6 were secondary. Initially, bridging TEVAR to control bleeding with concomitant subtotal esophagectomy and complete debridement of infected mediastinal tissue was performed. After a short interval, the patients underwent in situ aortic replacement with cryopreserved homografts or rifampicin-bonded Dacron grafts with omentopexy. Esophageal reconstruction was planned following general physical status improvement after 3-6 months. In-hospital mortality in the acute phase was 30%. Although the completion of the staged strategy achieving successful esophageal reconstruction was possible in 5 patients, no local relapses of infection were observed in these patients. Overall survival at 1 and 5 year were 68.6 and 42.9%, respectively.
  
  
  CONCLUSIONS
  The staged surgical treatment strategy for AEF consisted of prompt TEVAR to control bleeding with concomitant subtotal esophagectomy and subsequent in situ reconstruction of the aorta with an aortic homograft. This procedure enabled us to control local mediastinal infection with acceptable mortality. Avoiding delay in the diagnosis and initial treatment and resolving complications at each treatment step should further improve AEF treatment.
authors.affiliation: Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Seiryocho, Aoba-ku, Sendai, 980-8574, Japan, shunsukekawamoto@med.tohoku.ac.jp.
authors.forename: Shunsuke
authors.initials: S
authors.lastname: Kawamoto
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Sato
authors.forename: Naotaka
authors.initials: N
authors.lastname: Motoyoshi
authors.forename: Kiichiro
authors.initials: K
authors.lastname: Kumagai
authors.forename: Osamu
authors.initials: O
authors.lastname: Adachi
authors.forename: Takeshi
authors.initials: T
authors.lastname: Saito
authors.forename: Jin
authors.initials: J
authors.lastname: Teshima
authors.forename: Takashi
authors.initials: T
authors.lastname: Kamei
authors.forename: Go
authors.initials: G
authors.lastname: Miyata
authors.forename: Yoshikatsu
authors.initials: Y
authors.lastname: Saiki
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000150:complications / Q000601:surgery*; D004937:Esophageal Fistula / Q000150:complications / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D004947:Esophagus / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007564:Japan; D008297:Male; D012189:Retrospective Studies; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000601:surgery*; D058017:Vascular Grafting / Q000009:adverse effects / Q000379:methods* / Q000401:mortality