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iatrogenic trauma resulting in aorto-oesophageal fistula

Dave Napoliello nappio at aol.com
Fri Nov 26 15:12:35 GMT 2010


if this isnt repaired it is going to get infected.  open chest and fix everything
.dn
Sent from my Verizon Wireless Phone

Massimo Chiarugi <m.chiarugi at dc.med.unipi.it> wrote:

>Sure, it is not a pure trauma case but Members' suggestions would be 
>strongly appreciated
>
>A 62-yrs old male developed right pleural empyema and sub-diaphragmatic 
>abscess due to a leaked oesophago-jejunal ansatomosis seven days after 
>total gastrectomy for T2N0 gastric cancer. After VATS for pleural cavity 
>debridment and chest tubes drainage, a re-laparatomy was made. The 
>purulent collection was drained and  the anastomosis was not taken down: 
>the leak was covered by inserting endoscopically a plastic esophageal 
>prosthesis that passed through the anastomosis in the jejunum.The 
>proximal end of the prosthesis was then fixed to the mucosa of the 
>mid-third of the esophagus by titanium endoclips. In a two-month-course, 
>the patient did well: sepsis resolved, the esophago-pleural fistula and 
>the leak healed and oral intake was resumed. The day before the date 
>planned for prosthesis removal, patient had a severe episode of upper 
>digestive hemorrhage with shock. At endoscopy, the prosthesis had moved 
>into the jejunum and a severe arterial ongoing bleeding was seen in the 
>mid-third of the esophagus in correspondence of the site where the wall 
>was previously bited by an endoclip. Bleeding was stopped by enflating 
>the esophageal ballon of a Sengstaken tube and patient was stabilized 
>with 12 blood units. Aorto-esophagel fistula was confirmed by CT-scan 
>and angiography. With Seldinger technique a vascular prosthesis was then 
>placed in the descending thoracic aorta and the fistula was closed. 
>Again, patient did well in the course. One month later, esophagoscopy  
>showed a full-thickness subcentimetric defect of the esophageal wall, 
>corresponding to the site of the aorto-esophageal fistula, by which it 
>was possible to see the vascular prosthesis. Patient was posed on 
>antibiotic treatment and parenteral nutrition. Nowdays six months have 
>passed from the endovascular procedure: patient has no signs of 
>infection without antibiotic treatment and normal oral intake has been 
>resumed since weeks. Unfortunately, a 5-mm full-thickness esophageal 
>wall defect is still present at endocopy perfomed last days, and what 
>worse, also the vascular prosthesis is still visible at the deep of the 
>defect.
>So what: watch and see?endoscopic procedure to cover the defect (eager 
>to know which)? thoracotomy?
>
>Thank you in advance
>
>Massimo Chiarugi
>
>
>Massimo Chiarugi, MD,FACS
>University of Pisa Medical School
>Department of Surgery
>Santa Chiara Hospital
>55, Via Roma
>56100 PISA, Italy
>
>m.chiarugi at dc.med.unipi.it
>--
>trauma-list : TRAUMA.ORG
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