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• A 50 years old male was transferred from other hospital.
• One day before referal, he was admitted to that hospital
because of severe epigastric pain, the doctor suspected peptic
perforation. Exploratory laparotomy was done and found
retroperitoneal hematoma in upper part of abdoment. The
wound was closed and the patient was transferred.
• CT angiogram was done after surgery, it showed large thoraco
abdominal aortic aneurysm – Crawford type 5
• CAG was done, it was normal.
• Left thoracotomy incision was made through 6th intercostal space. The
aneurysm extended from mid thoracic to just above celiac artery. The
maximal diameter was 10 cm.
• Hematoma surrounded the aneurysm.
• Left femoral vein was exposed but cannula could not be passed into
right atrium. So, the aorta was cross clamped just above the
aneurysm. It was opened, clots evacuated, and transected above
celiac artery.
• A 22 mm dacron graft was anastomosed to distal aorta first , and
proximal anastomosis was completed. Aortic clamps were released.
The operation and his post operative course was uneventful. Until post
operative day 14, he complained of dysphagia and vomitting. He
was febrile and chilled.
• Chest CT scan showed presence of air in aneurysmal sac
surrounding the graft
• Emergency left thoracotomy was done.
• A large amount of pus and food particles surrounding the graft.
• Longituidinal necrosis of lower esophagus about 2 cm long.
• Esophagectomy was done with closure of cardia.
• Debridement and excision of aneurysmal wall and cleansing of
• Open diaphragm and mobilize omental flap.
• Cover the graft with omental flap.
• Gastrostomy, feeding jejunostomy and cervical esphagectomy
were done.
• Aortic wall
Streptococcal fecalis
• Pus
Steptococcus fecalis
Yeast cell
• Clinically well, he became afebrile and he tolerated
jejunostomy feeding fairly.
• Two weeks later reopened midline laparotomy was done, while
mobilizing the cardia, there was pus from the aneurysmal sac,
the omental flap covered the graft well and no necrotic tissue,
the space was cleaned and irrgated.
• A redivac drain was left in the aneurysmal sac and the
abdomen was closed
• Post operatively he was well, tolerated jejunostomy feeding,
two weeks later the redivac drain was removed and IV
antibiotic continued for total two months.
• He was discharged to the referring hospital.
• 3 months after previous admission, he was well and wanted to
drink and eat by mouth.
• Repeated CT chest showed small about of fluid in the
aneurysmal sac, much smaller than before.
• Right thoracotomy was done and total thoracic esophagectomy
was done
• One week later, the abdomen was reopened, left side colon
was mobilized preserving left colic vessel and the colon was
pulled up via retrosternal space and anastomosed to cervical
esophagus. Cologastrostomy, colo-colostomy were done.
• There was superficial abdominal wound infection.
• His post operative course was uneventful otherwise.
• Oral diet was resumed on 8th post operative day after contrast
study showed no leakage no obstruction.
• Esophageal necrosis after surgery of descending thoracic aortic
aneurysm is not rare.
• Mechanisms
ruptured aneurysm caused pressure on the esophagus
surgery excluded aortic branches to esophagus, ischemic
• Prognosis is almost always fatal due to
sepsis, mediastinitis
prosthetic graft infection
extra anatomical bypass – difficult or impossible
infection involving suture lines – aortic anastomotic dehiscence
-> fatal hemorrhage
• Omental graft
blood supply and white blood cell to combat bacteria
cover the prosthetic graft is an important strategy to combat
graft infection
filling the space surrounding the graft prevent reinfection
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