Analysis of risk factors and classification of aortic fistula after esophagectomy

Background: Aortic fistula after esophagectomy is a rare and serious complication. The aims of this study were to describe the causes of and classify the fistulas. Materials and methods: Between January 2008 and December 2017, a total of 1018 patients underwent esophageal resection, mainly for esophageal cancer; aortic fistula after esophagectomy was diagnosed in four patients. We perform a literature review through a database search for similar cases. Aortic fistulas may be classified into two types based on the site at which they occur in relation to the alimentary tract and area of anastomosis. Type 1 fistula occurs within the area of anastomosis, whereas type 2 fistula occurs above or below the anastomosis. The risk factors and clinical features associated with aortic fistulas are described, and comparison between the two types is made. Results: Through a literature search, 39 cases were identified, of which 26 cases were classified as type 1, and 13 cases were classified as type 2. Of 13 patients (33.3%) who underwent emergent intervention, seven patients survived. Approximately 76.9% of aortic fistula were related to anastomotic fistula, which was more prevalent in type 1 aortic fistula than in type 2 (92% versus 50%, P = 0.005). There was no statistically significant difference in age, gender, side of thoracotomy, type of anastomosis, the postoperative day the hemorrhage occurred, warning hemorrhage, chest pain, or the outcome between the two types of fistula. Conclusions: Anastomotic fistula is the primary cause of type 1 aortic fistula after esophagectomy, and early diagnosis and intervention of aortic fistula can improve prognosis. This classification may be a useful guide in determining the approach for second-stage alimentary tract reconstruction. (C) 2018 Elsevier Inc. All rights reserved.