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• W2029858452 abstract "The presence of an aberrant right subclavian artery represents a potentially risky situation when high mediastinal surgery is planned. We report a case of a patient needing transhiatal esophagectomy for cancer; the presence of the abnormal anatomic arterial situation complicated the postoperative course, when a vascular- digestive fistula appears. We discuss the direct causes and consequences of a rare situation. The presence of an aberrant right subclavian artery represents a potentially risky situation when high mediastinal surgery is planned. We report a case of a patient needing transhiatal esophagectomy for cancer; the presence of the abnormal anatomic arterial situation complicated the postoperative course, when a vascular- digestive fistula appears. We discuss the direct causes and consequences of a rare situation. Transhiatal esophagectomy (THE) for cancer is proposed in order to decrease postoperative morbidity [1Pop D. Venissac N. Mouroux J. Video-assisted mediastinoscopy improved radical resection for cancer in transhiatal esophagectomy.J Thorac Cardiovasc Surg. 2007; 133: 267-268Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. The major inconvenience is blind mediastinal dissection. In addition, the presence of an aberrant right subclavian artery (ARSA) can complicate the preoperative or postoperative course [2Hollander J.E. Quick G. Aortoesophageal fistula: a comprehensive review of the literature.Am J Med. 1991; 91: 279-287Abstract Full Text PDF PubMed Scopus (219) Google Scholar, 3Millar A. Rostom A. Rasuli P. Saloojee N. Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature.Can J Gastroenterol. 2007; 20: 389-392Google Scholar, 4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. We present the case of a patient with a fistula between an ARSA and a gastric transplant after THE, and we discuss the causes and consequences.A 67-year-old man was admitted to our department for the surgical treatment of esophageal cancer. His past medical history included an upper left lung lobectomy for adenocarcinoma 25 years before the present surgery, followed 6 years later by completion left pneumonectomy for squamous cancer. Eighteen months before the present surgery, he suffered from thoracic trauma (rib fractures and right pneumothorax) needing mechanical ventilation. During the recovery period (6 months), several computed tomographic scans revealed a hepatic nodule, whose size remained stable. A complete check-up was made after, and the diagnosis of neuroendocrine low-grade liver carcinoma was made. At the same time, the 18-fluorodeoxyglucose-positron emission tomography scan revealed an anomalous lesion in the esophagus. A squamous esophageal carcinoma classified T2N0 was diagnosed (28 cm from the incisors). Because of the patient's medical history, chemotherapy was chosen as treatment. At the end of the treatment, the check-up revealed an unchanged carcinoma.An extensive cardiorespiratory evaluation was performed. Spirometry showed the following: forced expiratory volume in the first second of expiration = 1.3 L (39%), forced vital capacity = 2.7 L (64%), diffusing capacity of lung for carbon monoxide = 64%; normal arterial blood gases; normal cardiac function; and the exercise testing showed a maximum oxygen consumption = 17 mL/kg per minute. As the chemotherapy had no effect on the tumor (the patient was in relatively good health, except for the lung function, and he no longer wanted medical therapy), THE was decided on by the multidisciplinary staff. In our unit, THE is done under video-assisted mediastinoscopy (VAM) control [1Pop D. Venissac N. Mouroux J. Video-assisted mediastinoscopy improved radical resection for cancer in transhiatal esophagectomy.J Thorac Cardiovasc Surg. 2007; 133: 267-268Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]; an ARSA was diagnosed in this patient.The surgery (240 minutes) was uneventful. An anastomotic cervical fistula was diagnosed on postoperative day (POD) 12, managed by reopening and drainage; nutrition was maintained through jejunostomy tube feedings. After an uneventful recovery period (the cervical wound was closed, the patient ate orally), he presented a massive hematemesis on POD 40. Emergent surgical exploration was done but no abdominal or cervical active bleeding was noticed. Further endoscopy was performed and the source of bleeding was found to come from an arterioesophageal fistula, 3 to 4 cm below the anastomosis. Hemostasis was accomplished with Blakemore tube compression. The arteriography identified the active bleeding of the lusoria artery and stenting was performed. The patient's course improved but anastomotic stricture appeared requiring esophageal dilation and stenting (on POD 100). On POD 125, while the patient was recovering well (normal feeding, etc), cataclysmic hematemesis occurred. In spite of emergency surgery, the patient died. Histology showed a small pT2N0R0 squamous cancer.CommentThough rare, ARSA (lusoria artery) is the most common abnormality of the aortic arch. The aberrant vessel will not generate a spontaneous arterioesophageal fistula unless it undergoes aneurismal dilation or extrinsic compression with pressure necrosis from a nasogastric or endotracheal tube. In an extensive review of literature, in 1991 [2Hollander J.E. Quick G. Aortoesophageal fistula: a comprehensive review of the literature.Am J Med. 1991; 91: 279-287Abstract Full Text PDF PubMed Scopus (219) Google Scholar] there was only 1 aortoesophageal fistula found in the case of a prior esophagectomy. Since then, only 1 case has been published [3Millar A. Rostom A. Rasuli P. Saloojee N. Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature.Can J Gastroenterol. 2007; 20: 389-392Google Scholar] in which the fistula was formed between the ARSA and the esophageal anastomotic ulcer site. The authors presumed that the fistula was a consequence of the pressure from the gastric pull-up procedure as well as erosion of the suture or staples line anastomosis. Our case, however, was different. In order to decrease the pressure of the blind mediastinal maneuvers during THE, we used VAM assistance [1Pop D. Venissac N. Mouroux J. Video-assisted mediastinoscopy improved radical resection for cancer in transhiatal esophagectomy.J Thorac Cardiovasc Surg. 2007; 133: 267-268Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. This technique allows accurate mediastinal dissection and visual control when stripping the esophagus. In our case VAM was useful to identify the ARSA and allowed for a smooth dissection between it and the esophagus. Secondly, the anastomosis was done well away from the artery in order to avoid contact between the artery and the gastric pull-up. Thus, we did not think it useful to interpose any muscle flap or other tissue.How did this fistula appear? There are several possible answers. First, the presence of cervical sepsis could have damaged the arterial wall. The diameter of ARSA was calculated at 17 mm on the preoperative computed tomographic scan (Fig 1) . Second, the staple line could have been in contact with the ARSA when the gastric tube was pulled up. We constructed the gastric conduit by repeated firings of thick-tissue gastrointestinal anastomosis. In our practice, the suture line is oversewn but we do not know if this is enough to avoid contact. The third explanation comes from the fact that the abnormal artery was drawn to the left due to the mediastinal shift caused by previous left pneumonectomy.The survival of patients depends on immediate, simultaneous diagnostic and therapeutic maneuvers. The endoscopy and balloon tamponade allows control of massive hemorrhage, and surgical exploration can rule out other bleeding sources [4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Right thoracotomy is recommended by several authors [4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] for surgical exploration and for repairs of the artery and the digestive tract. Our patient had had previous left pneumonectomy, and a transsternal approach would have solved only the arterial problem. We took the option of an endovascular stent in the ARSA.After repeated esophageal maneuvers and cervical leakage, anastomotic stricture occurs at the site of gastroesophageal suture, requiring dilation and esophageal stenting. The presence of 2 self-expanding metal stents leads to pressure necrosis of the arterial and digestive wall, which in turn causes active bleeding, subsequent cardiac arrest, and death.When esophageal surgery is planned, the presence of a lusoria artery must be considered as a high-risk factor in the development of a fistula. Temporary intraesophageal balloon tamponade is successful, but prolonged pressure devices such as esophageal or arterial stents should be avoided in order to prevent devastating consequences. The lesson to be learned: beware of a lusoria artery during transhiatal esophagectomy! Transhiatal esophagectomy (THE) for cancer is proposed in order to decrease postoperative morbidity [1Pop D. Venissac N. Mouroux J. Video-assisted mediastinoscopy improved radical resection for cancer in transhiatal esophagectomy.J Thorac Cardiovasc Surg. 2007; 133: 267-268Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. The major inconvenience is blind mediastinal dissection. In addition, the presence of an aberrant right subclavian artery (ARSA) can complicate the preoperative or postoperative course [2Hollander J.E. Quick G. Aortoesophageal fistula: a comprehensive review of the literature.Am J Med. 1991; 91: 279-287Abstract Full Text PDF PubMed Scopus (219) Google Scholar, 3Millar A. Rostom A. Rasuli P. Saloojee N. Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature.Can J Gastroenterol. 2007; 20: 389-392Google Scholar, 4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. We present the case of a patient with a fistula between an ARSA and a gastric transplant after THE, and we discuss the causes and consequences. A 67-year-old man was admitted to our department for the surgical treatment of esophageal cancer. His past medical history included an upper left lung lobectomy for adenocarcinoma 25 years before the present surgery, followed 6 years later by completion left pneumonectomy for squamous cancer. Eighteen months before the present surgery, he suffered from thoracic trauma (rib fractures and right pneumothorax) needing mechanical ventilation. During the recovery period (6 months), several computed tomographic scans revealed a hepatic nodule, whose size remained stable. A complete check-up was made after, and the diagnosis of neuroendocrine low-grade liver carcinoma was made. At the same time, the 18-fluorodeoxyglucose-positron emission tomography scan revealed an anomalous lesion in the esophagus. A squamous esophageal carcinoma classified T2N0 was diagnosed (28 cm from the incisors). Because of the patient's medical history, chemotherapy was chosen as treatment. At the end of the treatment, the check-up revealed an unchanged carcinoma. An extensive cardiorespiratory evaluation was performed. Spirometry showed the following: forced expiratory volume in the first second of expiration = 1.3 L (39%), forced vital capacity = 2.7 L (64%), diffusing capacity of lung for carbon monoxide = 64%; normal arterial blood gases; normal cardiac function; and the exercise testing showed a maximum oxygen consumption = 17 mL/kg per minute. As the chemotherapy had no effect on the tumor (the patient was in relatively good health, except for the lung function, and he no longer wanted medical therapy), THE was decided on by the multidisciplinary staff. In our unit, THE is done under video-assisted mediastinoscopy (VAM) control [1Pop D. Venissac N. Mouroux J. Video-assisted mediastinoscopy improved radical resection for cancer in transhiatal esophagectomy.J Thorac Cardiovasc Surg. 2007; 133: 267-268Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]; an ARSA was diagnosed in this patient. The surgery (240 minutes) was uneventful. An anastomotic cervical fistula was diagnosed on postoperative day (POD) 12, managed by reopening and drainage; nutrition was maintained through jejunostomy tube feedings. After an uneventful recovery period (the cervical wound was closed, the patient ate orally), he presented a massive hematemesis on POD 40. Emergent surgical exploration was done but no abdominal or cervical active bleeding was noticed. Further endoscopy was performed and the source of bleeding was found to come from an arterioesophageal fistula, 3 to 4 cm below the anastomosis. Hemostasis was accomplished with Blakemore tube compression. The arteriography identified the active bleeding of the lusoria artery and stenting was performed. The patient's course improved but anastomotic stricture appeared requiring esophageal dilation and stenting (on POD 100). On POD 125, while the patient was recovering well (normal feeding, etc), cataclysmic hematemesis occurred. In spite of emergency surgery, the patient died. Histology showed a small pT2N0R0 squamous cancer. CommentThough rare, ARSA (lusoria artery) is the most common abnormality of the aortic arch. The aberrant vessel will not generate a spontaneous arterioesophageal fistula unless it undergoes aneurismal dilation or extrinsic compression with pressure necrosis from a nasogastric or endotracheal tube. In an extensive review of literature, in 1991 [2Hollander J.E. Quick G. Aortoesophageal fistula: a comprehensive review of the literature.Am J Med. 1991; 91: 279-287Abstract Full Text PDF PubMed Scopus (219) Google Scholar] there was only 1 aortoesophageal fistula found in the case of a prior esophagectomy. Since then, only 1 case has been published [3Millar A. Rostom A. Rasuli P. Saloojee N. Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature.Can J Gastroenterol. 2007; 20: 389-392Google Scholar] in which the fistula was formed between the ARSA and the esophageal anastomotic ulcer site. The authors presumed that the fistula was a consequence of the pressure from the gastric pull-up procedure as well as erosion of the suture or staples line anastomosis. Our case, however, was different. In order to decrease the pressure of the blind mediastinal maneuvers during THE, we used VAM assistance [1Pop D. Venissac N. Mouroux J. Video-assisted mediastinoscopy improved radical resection for cancer in transhiatal esophagectomy.J Thorac Cardiovasc Surg. 2007; 133: 267-268Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. This technique allows accurate mediastinal dissection and visual control when stripping the esophagus. In our case VAM was useful to identify the ARSA and allowed for a smooth dissection between it and the esophagus. Secondly, the anastomosis was done well away from the artery in order to avoid contact between the artery and the gastric pull-up. Thus, we did not think it useful to interpose any muscle flap or other tissue.How did this fistula appear? There are several possible answers. First, the presence of cervical sepsis could have damaged the arterial wall. The diameter of ARSA was calculated at 17 mm on the preoperative computed tomographic scan (Fig 1) . Second, the staple line could have been in contact with the ARSA when the gastric tube was pulled up. We constructed the gastric conduit by repeated firings of thick-tissue gastrointestinal anastomosis. In our practice, the suture line is oversewn but we do not know if this is enough to avoid contact. The third explanation comes from the fact that the abnormal artery was drawn to the left due to the mediastinal shift caused by previous left pneumonectomy.The survival of patients depends on immediate, simultaneous diagnostic and therapeutic maneuvers. The endoscopy and balloon tamponade allows control of massive hemorrhage, and surgical exploration can rule out other bleeding sources [4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Right thoracotomy is recommended by several authors [4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] for surgical exploration and for repairs of the artery and the digestive tract. Our patient had had previous left pneumonectomy, and a transsternal approach would have solved only the arterial problem. We took the option of an endovascular stent in the ARSA.After repeated esophageal maneuvers and cervical leakage, anastomotic stricture occurs at the site of gastroesophageal suture, requiring dilation and esophageal stenting. The presence of 2 self-expanding metal stents leads to pressure necrosis of the arterial and digestive wall, which in turn causes active bleeding, subsequent cardiac arrest, and death.When esophageal surgery is planned, the presence of a lusoria artery must be considered as a high-risk factor in the development of a fistula. Temporary intraesophageal balloon tamponade is successful, but prolonged pressure devices such as esophageal or arterial stents should be avoided in order to prevent devastating consequences. The lesson to be learned: beware of a lusoria artery during transhiatal esophagectomy! Though rare, ARSA (lusoria artery) is the most common abnormality of the aortic arch. The aberrant vessel will not generate a spontaneous arterioesophageal fistula unless it undergoes aneurismal dilation or extrinsic compression with pressure necrosis from a nasogastric or endotracheal tube. In an extensive review of literature, in 1991 [2Hollander J.E. Quick G. Aortoesophageal fistula: a comprehensive review of the literature.Am J Med. 1991; 91: 279-287Abstract Full Text PDF PubMed Scopus (219) Google Scholar] there was only 1 aortoesophageal fistula found in the case of a prior esophagectomy. Since then, only 1 case has been published [3Millar A. Rostom A. Rasuli P. Saloojee N. Upper gastrointestinal bleeding secondary to an aberrant right subclavian artery-esophageal fistula: a case report and review of the literature.Can J Gastroenterol. 2007; 20: 389-392Google Scholar] in which the fistula was formed between the ARSA and the esophageal anastomotic ulcer site. The authors presumed that the fistula was a consequence of the pressure from the gastric pull-up procedure as well as erosion of the suture or staples line anastomosis. Our case, however, was different. In order to decrease the pressure of the blind mediastinal maneuvers during THE, we used VAM assistance [1Pop D. Venissac N. Mouroux J. Video-assisted mediastinoscopy improved radical resection for cancer in transhiatal esophagectomy.J Thorac Cardiovasc Surg. 2007; 133: 267-268Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. This technique allows accurate mediastinal dissection and visual control when stripping the esophagus. In our case VAM was useful to identify the ARSA and allowed for a smooth dissection between it and the esophagus. Secondly, the anastomosis was done well away from the artery in order to avoid contact between the artery and the gastric pull-up. Thus, we did not think it useful to interpose any muscle flap or other tissue. How did this fistula appear? There are several possible answers. First, the presence of cervical sepsis could have damaged the arterial wall. The diameter of ARSA was calculated at 17 mm on the preoperative computed tomographic scan (Fig 1) . Second, the staple line could have been in contact with the ARSA when the gastric tube was pulled up. We constructed the gastric conduit by repeated firings of thick-tissue gastrointestinal anastomosis. In our practice, the suture line is oversewn but we do not know if this is enough to avoid contact. The third explanation comes from the fact that the abnormal artery was drawn to the left due to the mediastinal shift caused by previous left pneumonectomy. The survival of patients depends on immediate, simultaneous diagnostic and therapeutic maneuvers. The endoscopy and balloon tamponade allows control of massive hemorrhage, and surgical exploration can rule out other bleeding sources [4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Right thoracotomy is recommended by several authors [4Miller R.G. Robie D.K. Davis S.L. et al.Survival after aberrant right subclavian artery – esophageal fistula: case report and literature review.J Vasc Surg. 1996; 24: 271-275Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] for surgical exploration and for repairs of the artery and the digestive tract. Our patient had had previous left pneumonectomy, and a transsternal approach would have solved only the arterial problem. We took the option of an endovascular stent in the ARSA. After repeated esophageal maneuvers and cervical leakage, anastomotic stricture occurs at the site of gastroesophageal suture, requiring dilation and esophageal stenting. The presence of 2 self-expanding metal stents leads to pressure necrosis of the arterial and digestive wall, which in turn causes active bleeding, subsequent cardiac arrest, and death. When esophageal surgery is planned, the presence of a lusoria artery must be considered as a high-risk factor in the development of a fistula. Temporary intraesophageal balloon tamponade is successful, but prolonged pressure devices such as esophageal or arterial stents should be avoided in order to prevent devastating consequences. The lesson to be learned: beware of a lusoria artery during transhiatal esophagectomy! The authors thank Ms Helen Jardine, translator and language editor in Nice, France, for her help in the translation process." @default.
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• W2029858452 title "Lesson to Be Learned: Beware of Lusoria Artery During Transhiatal Esophagectomy" @default.
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