Fatal aortogastric fistula following fully covered metal stent placement for refractory esophageal stricture

A 45-year-old woman with a history of systemic sclerosis presented with a postanastomotic gastric tube stenosis 1 year after esophagus resection and gastric tube interposition for a ypT3N1M0 adenocarcinoma of the esophagus. She was also treated with neo-adjuvant chemoradiation therapy [1]. Endoscopy identified a post-anastomotic esophageal stenosis extending from 24cm to 32cm aborally. She had shown only a limited response to 23 Savary dilations and one balloon dilation in 9 months. We therefore decided to use an 18×12cm fully covered metal stent (Evolution; Cook Medical Inc., Bloomington, Indiana, USA) across the stenosis. The patient presented 3 weeks after stent deployment with massive hematemesis and hemodynamic instability. Emergency endoscopy revealed a massive amount of blood and a distally displaced stent (●" Fig.1a,b), but no active bleeding was seen. A second endoscopy in the intensive care unit revealed a massive amount of blood in the esophagus, but still without a visible cause. Because the patient now required resuscitation (there was no measurable blood pressure), she was transferred to the operating theater. An emergency thoraco-laparo-phrenicotomy was performed and a bleeding source from the aorta was identified and manually occluded. Unfortunately, by this time the patient did not show any cardiac activity in spite of direct cardiac massage and chemical resuscitation, and she died during surgery. A post-mortem full-body computed tomography scan and autopsy revealed an aortogastric fistula on the downwards -migrated distal part of the esophageal stent (●" Fig.1b,c). An aorto-esophageal fistula (AEF) is an infrequent, but mostly fatal complication after esophagectomy [2,3]. Thoracic aortic aneurysms are the most common cause of AEF; further causes include foreign body ingestion, trauma (usually iatrogenic), carcinoma or, rarely, tuberculous aortitis [3]. The literature on esophageal stentrelated AEF is scarce, and can be classified as follows. 1. Anastomic-aortic fistula ▶ after anastomotical leakage and esophageal stent placement (aortic pressure and local inflammation) [3] ▶ after anastomotical stenosis and stent placement (aortic pressure and possible local perforation) [4,5] 2. Benign esophageal stricture-aortic fistula after stent placement (aortic pressure and possible local perforation) [6] 3. Direct stent perforation-induced aortic fistula ▶ non-migrated stent [7] ▶ migrated stent (the current case).