Comment
Esophageal penetration caused by accidental foreign body ingestion is
uncommon, with a reported incidence of 1–4% [2].
Additionally, AEF is rare; Nandi et al. [3]reported that only 1% of patients had esophageal perforation caused by
swallowing fish or chicken bones among 2394 cases of foreign body
ingestion, and 0.1% of these patients developed AEF. Given the low rate
of occurrence, it is not unexpected that there are no established
treatment guidelines for AEF.
According to the article by Takeno et al., which reviewed trends of AEF
management, thoracic endovascular aortic repair (TEVAR) was typically
preferred over surgery for aortic lesions. In contrast, esophagectomy
was preferred for esophageal lesions to remove the original infectious
source [4], as was the case for our patient. This
trend might have reflected the minimal invasiveness of TEVAR compared
with surgical procedures for the thoracic aorta, which needed a
cardiopulmonary bypass, leading to increased bleeding risk.
Aortic pseudoaneurysm could have developed secondary to the infectious
mediastinitis [5]. Although there was no clear
evidence of aortic lesion at the first observation in this case (Fig
1A), a small but expanding pseudoaneurysm was observed during subsequent
radiologic follow-up (Fig 2A-C). The weakness of the aortic wall
attributed to an adventitial tear combined with mediastinitis might have
contributed to the rapidly growing pseudoaneurysm. Therefore, if
esophageal perforation is diagnosed, CT angiography should be performed
as soon as possible to ensure the early detection of any vascular
problems, such as aortic rupture or aneurysm formation. Moreover, close
patient monitoring and surveillance should be considered, even if no
significant problem is detected upon initial examination.