CLINICS 2011;67(2):195-197 CASE REPORT DOI:10.6061/clinics/2012(02)19 A combined minimally invasive approach for the treatment of aortoesophageal fistula caused by the ingestion of a chicken bone: case report and literature review Xiaodong Chen,I Jianwen Li,I Jie Chen,II Yu Zhou,III Yuanqi Zhang,I,IV Hongfei Ding,I Shuichuan Huang,I Zhi ZhangI I Affiliated Hospital of Guangdong Medical College, Department of Vascular Surgery, Zhanjiang, Guangdong province, People9s Republic of China. II Affiliated Hospital of Guangdong Medical College, Department of Cardiothoracic Surgery, Zhanjiang, Guangdong province, People9s Republic of China. III Affiliated Hospital of Guangdong Medical College, Department of Gastroenterology, Zhanjiang, Guangdong province, People’s Republic of China. IV First Affiliated Hospital of Sun Yat-sen University, Research Center of Vascular Surgery, Department of Vascular Surgery, the Guangzhou, People’s Republic of China, Guangdong, China. Email: gdyfywjk@163.com Tel.: 86 759-2369322 INTRODUCTION Aortoesophageal fistula (AEF) is a rare, catastrophic complication that can be caused by the ingestion of a foreign body (1,2). In the past, AEF was treated with surgical repair using thoracic esophagectomy and esophagogastrostomy. However, the mortality rate for patients with AEF remains extremely high (2-4). Recently, we successfully treated a patient with AEF that was caused by the ingestion of a chicken bone. We placed an aortic endovascular stent graft followed by thoracoscopic mediastinal debridement and drainage. A retrievable esophageal stent was placed to isolate the fistula, which was removed after 80 days. In this report, we present our experience using a combined minimally invasive therapeutic approach for the treatment of AEF. CASE DESCRIPTION A 22-year-old man was admitted to our hospital on March 28, 2011 complaining of seven days of retrosternal discomfort and a single episode of vomiting of approximately 50 mL of fresh red blood. The patient had swallowed a chicken bone prior to the onset of the discomfort. His vital signs were stable during physical examination, and there was no fever on arrival at the hospital. Laboratory findings revealed a white blood cell (WBC) count of 19.96109/L and hemoglobin (Hb) levels of 84 g/L. He vomited approximately 300 ml of bright red blood and produced a large amount of tarry stool on March 29, 2011. His Hb levels subsequently decreased to 73 g/L. CT angiography (CTA) demonstrated a mediastinal esophageal fistula with inflammatory exudate surrounding the descending aorta. An aortic pseudoaneurysm at the anterior wall of the descending aorta was also observed at the Copyright 2011 CLINICS – This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. No potential conflict of interest was reported. 195 lower edge of thoracic vertebrate 5 (Figure 1). A diagnosis of AEF was highly suspected. Angiography was performed on March 31, 2011 and showed a 0.7 cm60.4 cm pseudoaneur- ysm of the descending aorta approximately 4.5 cm below the origin of the left subclavian artery, which was consistent with the results of the CTA. This finding confirmed the diagnosis of AEF. After an immediate multidisciplinary discussion, a plan for definitive treatment was established. An endovas- cular stent-graft (catalog number: TF2424C200X, Medtronic, Inc., USA) was placed inside the descending aorta to isolate the pseudoaneurysm. Postoperative angiography showed satisfactory exclusion results, and the patient was transferred to the operating room for thoracoscopic exploration. Swelling in the esophageal bed and inflammatory exudates were observed under the thoracoscope. Immediate mediastinal debridement and irrigation was performed using the thoracoscope. Two F16 silicone tubes were placed in the pleural cavity and the mediastinum to facilitate postoperative drainage. The patient underwent an esophageal endoscopy, and an esophageal fistula approximately 1.0 cm in diameter was found 25 cm away from the incisors (Figure 2A). A single-use retrievable esophageal stent-graft (Micro-Tech Co., Ltd. Nanjing China, length 8.0 cm, diameter 2.0 cm) was implanted to isolate the esophageal perforation followed by the placement of a three-lumen gastrojejunal tube for additional enteral nutrition. After spending three days in the intensive care unit (ICU), the patient was transferred back to our department. He had no melena and no fever or vomiting, and the mediastinal and pleural drainage gradually became clear. On the 7th day after the operation, esophageal imaging with meglumine diatrizoate showed no leakage, and the three-lumen gastrojejunal tube was removed. The patient was provided with a liquid diet. Both of the drainage tubes in the pleural cavity and the mediastinum were removed 25 days after the operation. Repeat CTA confirmed successful tamponade of the fistula 40 days after the operation (Figure 3). Antibiotic treatment was administered during hospitaliza- tion. Laboratory findings showed that the patient’s WBC count was 23.06109/mL with 79.1% neutrophils (NEs) on the second day after the operation. The WBC count and