Department of General and Thoracic Surgery, Klinikum Nürnberg Nord, Nürnberg, Germany.
Ann Thorac Surg. 2011 Aug;92(2):513-8. doi: 10.1016/j.athoracsur.2011.02.083. Epub 2011 May 18.
Intrathoracic anastomotic leakage after esophagectomy is associated with high morbidity and mortality. Because of disappointing results after surgical reexploration endoscopic stent implantation was introduced as primary treatment option with improved outcome. Aortoesophageal fistula is a very rare complication and has thus far only anecdotally been reported after esophagectomy. The aim of this retrospective study was to investigate if endoscopic stent implantation increases the incidence of postoperative aortoesophageal fistula by reason of stent-related erosion of the thoracic aorta.
Between January 2004 and October 2010, 213 patients underwent esophageal resection mainly for esophageal cancer. An intrathoracic esophageal anastomotic leak was endoscopically verified in 25 patients. Seventeen patients received endoscopic implantation of a self-expanding stent as primary treatment. In 8 patients a rethoracotomy was mandatory.
After successfully accomplished endoscopic stent placement, complete closure of the anastomotic leak was radiologically proven in all 17 patients. In 13 cases, definitive closure and healing of the leak was achieved and the stent could subsequently be removed. In 1 patient, because of early recurrence of very malignant small cell cancer, the stent remained in situ. Three patients developed an erosion of the thoracic aorta with subsequent massive hemorrhage. The mean time between stent insertion and occurrence of aortoesophageal fistula was 26 days. All 3 patients died of exsanguination with severe hypovolemic shock. Postmortem examination confirmed an aortoesophageal fistula in each case.
While endoscopic stent implantation seems to be effective in the control of intrathoracic anastomotic leakage, nevertheless the incidence of aortoesophageal fistula caused by stent-related aortic erosion exceeds the thus far reported numbers. Awareness of this life-threatening complication after stent insertion is therefore mandatory.
食管切除术后的胸内吻合口瘘与高发病率和死亡率相关。由于手术再次探查的结果令人失望，内镜支架植入术已被引入作为主要治疗选择，并取得了改善的结果。主动脉食管瘘是一种非常罕见的并发症，迄今为止仅在食管切除术后有过报道。本回顾性研究的目的是调查内镜支架植入术是否会因支架相关的胸主动脉侵蚀而增加术后主动脉食管瘘的发生率。
2004 年 1 月至 2010 年 10 月，213 例患者主要因食管癌接受食管切除术。25 例患者经内镜证实存在胸内食管吻合口瘘。17 例患者接受内镜植入自膨式支架作为主要治疗。8 例患者需要再次开胸手术。
在成功完成内镜支架放置后，17 例患者的吻合口漏均经影像学证实完全闭合。在 13 例患者中，漏口得到了明确的闭合和愈合，随后可以取出支架。在 1 例患者中，由于早期复发非常恶性的小细胞癌，支架仍留在原位。3 例患者发生胸主动脉侵蚀，随后发生大出血。支架置入与主动脉食管瘘发生之间的平均时间为 26 天。所有 3 例患者均因大量出血和严重低血容量性休克而死亡。尸检证实了每个病例的主动脉食管瘘。
虽然内镜支架植入术似乎能有效控制胸内吻合口瘘，但支架相关的主动脉侵蚀引起的主动脉食管瘘的发生率超过了目前报道的数字。因此，在支架置入后必须意识到这种危及生命的并发症的发生。
