Aorto-esophageal fistula caused by fishbone ingestion: a case report on staged endovascular and endoscopic treatment

A 38-year-old male who underwent TEVAR for AEF was admitted to our hospital with esophageal fistula lasting from 4 months.

The patient while eating was stuck by a fishbone, and he consciously swallowed it by drinking water 4 months ago. On day 6, he developed chest pain, on day 8 melena, on day 9 fever, and then he was admitted to hospital. Esophagogastroduodenoscopy (EGD) showed an esophageal fistula of 30 cm from the incisors, about 3 mm in diameter with influx of bloody fluid, and accompanied by a hematoma and hyperemic mucosa (Fig. 1a). Chest CT revealed air bubbles in the mediastinum, suggesting esophageal perforation (Fig. 2a). Neither EGD nor CT found any signs of fish bones. Broad spectrum antibiotics and nasojejunal feeding was given. The patient after that developed sudden massive hematemesis and melena in 7 days. Enhanced CT showed formation of mediastinal abscess, pseudoaneurysm and contrast material extravasation from the aorta to esophagus (Fig. 2b–d), confirming the diagnosis of AEF. A thoracic endovascular stent graft (Zenith TX2 TAA ref ZTEG-2PT-32-160; Cook, Denmark) in 32-mm proximal and 28-mm distal diameter and 160-mm length was then implanted. His symptoms were improved, and discharged with a nasojejunal tube, and the esophageal fistula was assumed to heal on its own. About 4 months later, EGD again displayed the esophageal fistula of about 0.6 cm in diameter (Fig. 1b). He was then admitted to our hospital for esophageal repair. In the past 4 months, he ate through nasojejunal tube and lost 6 kg weight, and had no fever, hematemesis or melena.

The patient had no previous medical history and no specific family history.

At admission, the patient’s temperature was 36.5 °C, heart rate was 96 bpm, respiratory rate was 20 breaths per minute, blood pressure was 125/80 mmHg, height was 178 cm, and weight was 57.5 kg. No other special findings were reported.

Routine blood tests, including white blood cell count of 7.56 × 10⁹/L, mainly neutrophils 68.7%, hemoglobin concentration 134 g/L were normal. The blood biochemistries were also normal. The procalcitonin concentration of 0.13 ng/mL was shown to be slightly increased, and fecal occult blood was weakly positive.

Except for the radiopaque of well-positioned aortic stent and nasojejunal tube, there were no signs of infection on chest plain CT (Fig. 2e).

Aorto-esophageal fistula (after thoracic aortic stent implantation).

The patient had no signs of active infection and the aortic stent functioning was well, but the fistula was growing. Hence, 4 endoclips were used to close the fistula (Fig. 1c).

No postoperative complications occurred. He was discharged from the hospital the next day. At 1-month follow-up, EGD revealed the closure of the fistula (Fig. 1d). At 3-months follow-up, EGD revealed completely healed fistula and suspicious fungal esophagitis (Fig. 1e). Brush biopsy did not find any fungus, and so no treatment was given. The nasojejunal tube was removed and the patient was returned to normal diet. At 12 months, the patient had fever, and blood culture detected streptococcus anginosus. Endoscopic brush biopsy found yeast-like fungus, and routine urine test found yeast cells and routine stool test found fungus. Chest CT and angiography revealed no evidence of mediastinitis, aortic stent-graft infection, or new episodes of gastrointestinal bleeding (Fig. 2f). After combined treatment of aztreonam, vancomycin and voriconazole, the patient showed improvement and was discharged from the hospital. Re-examination by EGD revealed no signs of infection (Fig. 1f). In the last year, the patient gained 7 kg weight. The timeline of this case was shown in Fig. 3.