Sarcoidosis-Associated Aortoesophageal Fistula-Multistage Interdisciplinary Surgical Therapy for a Rare and Life-Threatening Condition.
Aortoesophageal fistulas (AEFs) are rare and life-threatening conditions. Till date, an association between an AEF and sarcoidosis has not been reported yet. The aim of this report is to demonstrate a case of AEF secondary to sarcoidosis and its multistage interdisciplinary surgical therapy. A 66-year-old male was diagnosed with sarcoidosis in 2014. He has been treated with glucocorticoids since then and no severe health restrictions due to the disease have occurred. In December 2015, the patient presented with acute thoracic pain and hematemesis: an esophagogastroscopy revealed an AEF. First, stent-graft implantation in the thoracic aorta was urgently performed as a "bridging" procedure. Second, esophagectomy and local debridement were performed, followed by explantation of the stent graft and reconstruction by means of xenograft replacement of the stented aorta in a third operation. Finally, retrosternal gastric pull-up was performed in a fourth operative procedure. Sixteen days after the last operation the patient could be discharged to a rehabilitation clinic. Follow-up is uneventful so far; the antibiotic therapy was stopped at the time of hospital discharge. The pathogenesis of sarcoidosis, a rare autoimmunological disease, has not been completely clarified yet. The diagnosis relies on clinical symptoms and radiological as well as histopathological findings. Many cases of sarcoidosis show spontaneous regression, but severe complications may occur. While tracheoesophageal fistulas have been described in the literature, AEFs related to sarcoidosis have not been mentioned yet. Despite surgical and antibiotic treatment, the morbidity and mortality rates of AEF are high. Because the endovascular treatment has been established for emergency procedures of the aorta, it is considered as an appropriate first-line "bridging" treatment option. To achieve good long-term results, surgical treatment has to involve esophagectomy with secondary reconstruction of the upper gastrointestinal tract, as well as open aortic replacement using xenograft or homograft material. Sarcoidosis may lead to AEF as demonstrated in this case. Successful treatment can be realized by a multistage interdisciplinary surgical approach.
Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany. Electronic address: agombert@ukaachen.de.
Alexander
A
Gombert
Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany.
Jochen
J
Grommes
Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine, Medizinisches Zentrum StädteRegion Aachen, Wurselen, Aachen, Germany.
Guido
G
Schick
Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany.
Marcel
M
Binnebösel
Department of General, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany.
Christian
C
Klink
Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany.
Michael J
MJ
Jacobs
Department of Vascular Surgery, European Vascular Center Aachen-Maastricht, University Hospital RWTH Aachen, Aachen, Germany.
Drosos
D
Kotelis
D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001018:Aortic Diseases / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation; D000072226:Computed Tomography Angiography; D003646:Debridement; D020878:Device Removal; D013505:Digestive System Surgical Procedures; D004630:Emergencies; D004937:Esophageal Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D016629:Esophagectomy; D004946:Esophagostomy; D005773:Gastroscopy; D005938:Glucocorticoids / Q000627:therapeutic use; D064593:Heterografts; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D010348:Patient Care Team; D012507:Sarcoidosis / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D015607:Stents; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*
D000900:Anti-Bacterial Agents; D005938:Glucocorticoids