Clinical Study Of Aortoesophageal Injury And Fistula Caused By Esophageal Foreign Boby

Objective Esophageal foreign body is a common clinical emergency.Although most esophageal foreign bodies can be discharged from the digestive tract without complications,there are still 10-20%of them need to be treated by endoscopy or surgery.The esophageal foreign body embedded here can form aortoesophageal injury or even aortoesophageal fistula,when it is taken out directly or directly.The success rate of aortoesophageal fistula is very low and the cost of treatment is high.This paper discusses the experience and lessons of aortoesophageal injury and fistula caused by thoracic esophageal foreign body and discusses the treatment methods for potential and clear aortoesophageal fistula.It can provide reference for the diagnosis and treatment of potential and clear treatment of aortoesophageal fistula cases in the future clinical work.Methods The clinical data of 4 cases of aortoesophageal injury and 4 cases of aortoesophageal fistula caused by thoracic esophageal foreign bodies from June 2016 to August 2019 were retrospectively analyzed including 5 males and 3 females,with ages ranging from 29 to 74 years.The time from swallowing the foreign body to seek medical advice ranged from 6 hours to 9 days,5 patients within 24 hours,1 patient for 4 days,2 patients for 8 days and 9 days respectively.The first 4 cases of aortoesophageal injury grade II,no obvious signs of direct injury such as the overflow of contrast media or diverticulum were found in the CTA or CT.The distance from the foreign body to the aorta was about 1.06mm,1.07mm,1.94mm,2.00mm respectively.Gastroscopy showed the distance from the foreign body to the incisor was about 23cm,30cm,25cm,23cm respectively.It was considered that there was potential or definite aortic injury,with potential aortoesophageal fistula because both ends of the foreign body penetrated into the wall of the thoracic esophagus.The latter 4 cases were confirmed to be aortoesophageal fistula by CTA or angiography.the first three cases of CT or CTA foreign bodies were close to the aortic arch,punctured into the descending aorta,penetrated the right wall of the aorta with pseudoaneurysm formation respectively.Gastroscopy showed that the distance between the damaged mucosa or the foreign body and the incisor was about 17-26cm,27cm,30cm respectively.In case 8,CT showed esophageal perforation with a small amount of pleural effusion on the right side,the distance from the foreign body to the aorta was about 7mm,gastroscope showed that the foreign body was about 24cm from the incisor teeth,After the foreign body was taken out under the endoscope for 36 hours,there was sentinel hemorrhage.Further CTA confirmed the aortoesophageal fistula.Case 5 was not accompanied with infection,and the other 3 cases were all accompanied with mediastinal infection.We choose the appropriate treatment plan,analyze the diagnosis and treatment process,outcome,follow-up results,and review the relevant literatureResult Case 1 underwent gastroscopy combined with endoscopic dilatation balloon to remove the foreign body,and the diet was opened one day after the operation;Case 2 under the general anesthesia of endotracheal intubation,the foreign body was taken out with the assistance of endoscopic dilation balloon,and the fluid was opened on the second day after operation;Case 3,under the general anesthesia of tracheal intubation,aortography before operation confirmed that there was no leakage of contrast agent.The foreign body was removed with the endoscopic dilation balloon,After one day of continuous observation,the catheter was pulled out and the food was opened 4 days after operation;Case 4 under the general anesthesia of tracheal intubation,aortography confirmed that there was no leakage of contrast medium before operation,foreign bodies were removed with the endoscopic dilation balloon,the diet was opened on the second day after operation;All patients were discharged within one week.There was no mediastinal infection in case 5,which was repaired by intrathoracic aortic aortic repair.On the second day,the foreign body was removed by gastroscope under general anesthesia and then treated conservatively.After 9 days of operation,the diet was opened and the patient was discharged after 17 days.Case 6 with mediastinal infection,the patient underwent the repair of the intrathoracic aorta,but failed to remove the foreign body under endoscopy,and then underwent left thoracotomy to remove the foreign body and mediastinal drainage,strong anti infection and enteral nutrition support.After 46 days of open diet,the patient was discharged after 2 months.Under gastroscope,it was observed that the foreign body straddled both sides of the esophagus and had a little blood oozing,and then it was directly removed from the endoscopy in case 7.CTA confirmed that aortoesophageal fistula was accompanied with mediastinal infection.It was proposed to repair the aortoesophageal cavity immediately,and the patient died of massive hematemesis.Aortoesophageal fistula was formed after removal of the foreign body in case 8.The repair of aortoesophageal fistula was performed immediately.After conservative treatment,such as anti-infection and nutritional support,the patient was given an open diet 15 days later.After 6 months of follow-up,he was hospitalized with intermittent fever and anti infection treatment.After 6 months,he died of bleeding due to recurrent aortoesophageal fistula.All the surviving cases were followed up for half a year without complicationsConclusion There are potential aortoesophageal fistulas in patients who with aortoesophageal injury of grade II and the distance between foreign bodies on CT and aorta?2mm,and no direct or indirect signs of AEF.Successful treatment of these patients can reduce the incidence of aortoesophageal fistulas.The treatment of potential aortoesophageal fistulas by endoscopic dilatation balloon assisted with gastroscopy under general anesthesia has the advantages of small trauma,high success rate,simple operation,fast recovery,high safety,few complications,good clinical effect,etc.,which is worthy of further clinical promotion.The edge of the foreign body is sharp adjacent to the aorta,and aortography can better judge the condition of aortic injury.At the same time,under the protection of the indwelling catheter,endoscopic dilatation balloon assisted extraction of the foreign body under gastroscope can improve the safety of the operation.TEVAR has the advantages of small trauma,rapid control of bleeding and effective protection of the aorta.It can be used as an effective first aid means to stabilize the aortic blood flow.TEVAR combined with endoscopic foreign body removal can be used as a radical treatment,when the aortic injury is slight,without AEF infection.For the patients who can't take out the foreign body under endoscopy or with mediastinal infection,the repair of TEVAR is an emergency bridging method,and the follow-up surgery such as esophagectomy,aortic prosthesis replacement,and esophageal second reconstruction is still needed.For the patients with long embedding time and the distance from the foreign body to the aorta on CT is more than 5mm,even if the esophageal injury imaging only shows localized infection,it may be a better operation way to take out the foreign body directly under the thoracoscope or the combination of thoracoscope and gastroscope.