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Ann Thorac Surg 2003;75:288-289
© 2003 The Society of Thoracic Surgeons

Case report

Esophageal-pericardial fistula with purulent pericarditis secondary to esophageal carcinoma presenting with tamponade

Jeddediah Kaufman, MDa, Nisa Thongsuwan, MDb, Eric Stern, MDb, Riyad Karmy-Jones, MDa*

a Department of Surgery, Seattle, Washington, USA
b Department of Radiology, University of Washington, Seattle, Washington, USA

Accepted for publication July 31, 2002.

* Address reprint requests to Dr Karmy-Jones, Division of Thoracic Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA
e-mail: karmy{at}u.washington.edu


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
A case of esophago-pericardial fistula secondary to esophageal carcinoma causing pericardial effusion and tamponade is presented. Palliation can be achieved effectively by limited thoracotomy, pericardial resection and drainage, and in selected cases esophageal stenting.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Pericardial effusion in the setting of esophageal carcinoma is most commonly related to radiation and/or chemotherapy, rarely to esophago-pericardial fistula [1]. We report a case of a 47-year-old male with known esophageal carcinoma and an esophagopericardial fistula causing cardiac tamponade requiring emergency surgical treatment.

A 47-year-old male presented with sharp chest pain radiating to the left neck, right chest, and down both arms after smoking crack cocaine. He was diaphoretic and tachypneic. Vital signs at presentation were blood pressure of 59/42 mm Hg, pulse of 76, temperature of 34.0°C and oxygen saturation of 94%. His medical history was significant for metastatic esophageal carcinoma with liver involvement documented by computed tomography 3 months prior to presentation. Cardiac enzymes ruled-out myocardial ischemia, and a spiral computed tomographic scan of the chest was obtained to evaluate pulmonary embolus, which revealed a moderate right pericardial effusion with air-fluid levels (Fig 1A). A fistula from the esophagus to the pericardium at the superior margin of the right ventricle was seen with air tracking into the pericardial sac (Figure 1B). The patient initially refused any invasive intervention.



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  		Fig 1. Computed tomographic scans of chest (lung windows) demonstrating (A) air fluid levels within pericardial sac (arrows) and (B) small fistula (long arrows) between esophagus (short arrow) and small air collection within the pericardium.

 
Initially fluid responsive, within 24 hours he required dopamine infusion and fluid resuscitation. During this period the patient changed his mind about interventions. Because echocardiography demonstrated moderate loculations, open drainage was required. A limited left anterolateral non-rib spreading thoracotomy was performed in the fifth intercostal space. The pericardium was tense and upon entering the sac, purulent yellow fluid under considerable pressure began draining into the chest. An increase in systolic blood pressure from 70 mm Hg to 110 mm Hg occurred immediately. After drainage, a 4-cm by 5-cm portion was excised and multiple adhesions taken down. A 24-French chest tube was used to drain the pericardial sac. The patient tolerated the operation well, requiring no further volume or inotropic support. However, the patient then refused an esophageal stent placement opting for comfort measures only. He died 7 days later. No malignant cells were identified. Cultures grew Streptococcus milleri and alpha hemolytic Streptococcus.


   Comment
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 Abstract
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 Comment
References
 
There are three cases of esophago-pericardial fistulas secondary to esophageal carcinoma reported in the literature [2–4]. More often such effusions are caused by other malignancies [1, 5]. Because of extensive adhesions, percutaneous drainage or subxiphoid approaches are often insufficient. Anterior thoracotomy with a minimal or non-rib spreading technique provides excellent exposure, ability to resect a large amount of pericardium, perform complete debridement, and avoids pain from rib spreading. In addition, the risk of sternal infection is avoided. Surgical excision or ablation of the fistula is possible and the treatment of choice for nonmalignant fistula. When curative therapy is not possible, this approach also provides the patient minimal morbidity, while resumption of oral intake and faster recuperation.

A series of 29 esophagopericardial fistulas, due to causes other than esophageal carcinoma, was reported in 1985 and concluded that surgical drainage of the effusion should occur first with elective operative closure of the fistula second [6]. A case of malignant esophagopericardial fistula resulting in tamponade treated by pericardial drainage followed by esophageal stent was reported in 1999. The perimyocarditis quickly resolved and the patient tolerated oral intake until his death 6 weeks later [2].

Patients with esophagopericardial fistulae can undergo effective palliation by pericardial drainage and subsequent esophageal stenting. If loculations are suspected based on radiographic or echocardiographic findings, a minimal anteriolateral, non-rib spreading thoracotomy will allow debridement and drainage with minimal pain. Further treatment with esophageal stenting and antibiotics can then help these patients regain oral intake and quality of life.


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 References
 

  1. Renshaw A.A., Nappi D., Sugarbaker D.J., Swanson S. Effusion cytology of esophageal carcinoma. Cancer 1997;81:365-372.[Medline]
  2. Kohl O., Schaffer R., Doppl W. [Purulent pericarditis as an initial manifestation of esophageal carcinoma]. Dtsch Med Wochenschr 1999;124:381-385.[Medline]
  3. Furak J., Olah T., Szendrenyi V., Horvath O.P., Balogh A. [Esophago-pericardial fistula caused by recurrent esophageal tumor]. Magy Seb 1999;52:89-91.[Medline]
  4. Navarro P., Heras M., Miro J.M., Mateu M. [Cardiac tamponade as the first manifestation of carcinoma of the esophagus]. Med Clin (Barc) 1992;98:661-662.
  5. Abiko M., Ohizumi H., Naruke Y., et al. [A case of lung cancer (small cell carcinoma) occurring esophago-pericardial fistula and purulent pericarditis]. Kyobu Geka 1999;52:969-971.[Medline]
  6. Konttinen M.P., Pitkaranta P.P., Heikkinen L.O., Talja M.T., Ala-Kulju K.V. Esophago-pericardial fistula. A case report and review of the literature. Thorac Cardiovasc Surg 1985;33:341-343.[Medline]



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