Fatal Aortoesophageal Fistula Following Neoadjuvant Chemoradiation and Robot-Assisted Esophagectomy for Stage IIIa Esophageal Adenocarcinoma: 2650

Esophageal cancer is the sixth leading cause of cancer death worldwide, with an estimated 15,500 yearly death total in the US alone. Management guidelines advocate neoadjuvant chemoradiation followed by esophagectomy for T1-T3, and regional T4 disease. Depending on malignancy location, various surgical resection techniques can be utilized, including more recently the robot assisted minimally invasive esophagectomy (RAMIE). 54 year-old female with longstanding gastroesophageal reflux disease (GERD) presented to an outside medical center with progressive dysphagia. Esophagogastroduodenoscopy (EGD) revealed a circumferential ulcerated mass at the GE junction. Biopsies, endoscopic ultrasound and positron emission tomography (PET) scan revealed a stage IIIa (T3N1M0) esophageal adenocarcinoma. Neoadjuvant chemoradiation was initiated, and at 5 months post cancer diagnosis, RAMIE with mediastinal drain placement was performed. Post-operative day 11, patient developed acute chest pain, computerized tomography (CT) chest scan noted an esophageal perforation. EGD confirmed a 3 cm anastomotic dehiscence, 23cm from the incisors, communicating with the mediastinum. Defect closure with the Apollo overstitch device (Apollo EndoSurgery, Austin, TX) was attempted; however, the sutures could not fasten the thin ulcerated tissue. A fully covered esophageal stent was placed, however the stent eventually migrated and was replaced with a partially covered stent. Post-operative day 32, patient suffered acute massive hematemesis with hemodynamic compromise. Repeat EGD with esophageal stent removal revealed active arterial bleeding at the anastomotic dehiscence site. Massive hematemesis intermittently recurred despite epinephrine injection therapy. Subsequent interventional radiology (IR) angiography was performed revealing the presence of an aortoesophageal fistula (AEF). During angiography, the patient coded and shortly thereafter was pronounced dead, autopsy was declined. AEF formation post esophagectomy is an exceedingly rare and often fatal complication that arises from an anastomotic leakage or peptic ulceration. The nidus dehiscence is often attributed to postsurgical ischemia, neoadjuvant chemoradiation and/or mediastinitis. In this particular case, mediastinitis was the likely underlying factor for AEF formation. Ultimately, it is important to recognize that AEF is a potential complication in patients with a documented post-esophagectomy anastomotic dehiscence.