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.