Ann Thorac Surg 2008;86:1967-1969. doi:10.1016/j.athoracsur.2008.05.064
© 2008 The Society of Thoracic Surgeons
Case Reports
Esophago-Pericardial Fistula During the Course of Primary Esophageal Carcinoma
Janusz W
odarczyk, MD, PhD*,
Henryk Olechnowicz, MD,
Piotr Koco
, MD
Department of General Thoracic Surgery, John Paul II Hospital, Cracow, Poland
Accepted for publication May 19, 2008.
* Address correspondence to Dr Wodarczyk, Department of General Thoracic Surgery, John Paul II Hospital, Pr
dnicka St 80, Cracow, 31-202, Poland (Email: j.wlodarczyk{at}szpitaljp2.krakow.pl).
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Abstract
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The study presented a case of an esophago-pericardial fistula during the course of primary esophageal carcinoma. The occurrence of this was insidious, with the first symptom being pericardial sac tamponade. After full diagnostics the patient was qualified for surgery. The patient was subjected to videothoracoscopy, left-sided thoracotomy, fenestration, and pericardial sac drainage, with placement of a self-expandable esophageal prosthesis. During the course of the disease the patient required bronchial tree patency restoration and prosthesis application. The patient survived 329 days.
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Introduction
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The esophago-pericardial fistula is a rarely observed complication of primary esophageal carcinoma [1, 2]. This can occur during the course of benign esophageal diseases such as reflux disease with esophageal ulceration penetrating toward the pericardial sac, as well as perforation of the esophageal diverticulum [3, 4]. Literature data also mentioned the ingestion of caustic substances and swallowing of foreign bodies (fish bones) as possible causes of perforation [4]. The previously mentioned complication usually develops during the course of advanced lung and stomach cancer and metastases to the mediastinum [5]. Esophago-pericardial fistulas also develop after esophageal cancer irradiation.
The patient was a 56-year-old man who was directed to the department of cardiology with suspicion of cardiac tamponade. On admission the patient complained of chest pain, weakness, transient fever amounting to 38°C, and loss of appetite. The physical examination revealed crepitations at the base of the right lung, tachypnea (22 bpm), and tachycardia (120 bpm). The chest roentgenogram and echocardiographic scan showed signs of cardiac tamponade. During pericardiocentesis, 600 mL of a turbid effusion was obtained. Cultures demonstrated the presence of Streptococcus constellatus without fungal and mycobacterium pathogens. After pericardial sac decompression, the patient's clinical condition significantly improved. During hospitalization frequent episodes of paroxysmal atrial fibrillation were observed with the ventricular rate amounting to 160/min.
Computer tomography of the chest demonstrated fluid levels with a presence of air in the pericardial sac, as well as dilated and irregularly stenosed esophageal lumen with infiltration of its wall, beginning from the tracheal bifurcation to the supradiaphragmatic segment (Figs 1A and 1B). In addition, diagnostics comprised esophagoscopy, which showed the presence of a 6-cm esophageal infiltration with a crater-like ulceration penetrating to the mediastinum. Bronchoscopy demonstrated isolated neoplastic cells in the left main bronchus. After obtaining histopathologic results, the patient was diagnosed with an esophago-pericardial fistula during the course of primary esophageal cancer.
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Fig 1. Computed tomographic scans of the esophago-pericardial fistula with visible fluid and air levels. (A) Medial plane. (B) Horizontal plane.
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The patient was qualified toward surgical intervention. The patient was subjected to a video-thoracoscopic left-sided thoracotomy, fenestration, drainage of the pericardial sac, and placement of a self-expandable esophageal prosthesis to the esophagus (Ultraflex; Boston Scientific, Natick, MA). The postoperative course proved uneventful and the patient received oral nutrition 3 days after the procedure. The patient was discharged from the hospital 16 days after the operation.
After oncological consultation, the patient was qualified for chemotherapy and received two cycles of it. Three months after the procedure the patient was subjected to patency restoration of the granulation tissue, which infiltrated the distal pole of the esophageal prosthesis and neoplastic infiltration of the left main bronchus using argon plasma. The patient was discharged from the hospital. After 2 months the patient once again required left main bronchus patency restoration with prosthesis "Y" implantation. After the procedure the patient required mechanical ventilation for a period of 48 hours due to respiratory insufficiency. After de-cannulation, we observed normal, efficient breathing. The patient was discharged from the hospital after 6 days and survived for a period of 34 days. The survival time since establishing the diagnosis amounted to 329 days.
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Comment
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The patient was admitted to the department of cardiology, and the clinical course of the disease was insidious, suggesting cardiac tamonade during the course of a purulent infection. After decompression we obtained a turbid effusion, and cultures showed the presence of Streptococcus constellatus pathogens. This constituted normal micro-flora in healthy subjects, being rarely the cause of infection during the course of esophageal carcinoma. Muto and co-authors [2] confirmed this by describing two cases of esophago-mediastinal fistulas accompanied by a pericardial abscess infected by Streptococcus intermedii, belonging to the same species as our pathogen.
Due to the advanced stage of the neoplastic process, the patient qualified for palliative therapy. The patient had a video-thoracoscopic, left-sided thoracotomy with fenestration and drainage of the pericardial sac, introduction of an esophageal prosthesis, followed by patency restoration, and implantation of the bronchial tree prosthesis. Thus, the patient survived 329 days, being the longest mentioned survival period in literature data. Other authors observed survival ranging between several days and 5 weeks. The short period of survival was connected with the severe condition of the patient at the time of diagnosis and therapy initiation [1, 6].
During the postoperative period, the patient received two cycles of chemotherapy. However, chemotherapy in case of esophago-pleural fistulas, as a complication of esophageal carcinoma remains controversial, because some authors demonstrated disease progression. Others observed fistula closure after chemotherapy [7]. Alexander and co-authors [7] considered that aggressive oncological management might improve treatment results in case of advanced esophageal cancer.
The esophago-pericardial fistula is a rare complication during the course of primary esophageal carcinoma, and the accompanying purulent cardiac tamponade is a life-threatening condition. Treatment of choice consists in palliative therapy (ie, decompression of the pericardial sac, esophageal, and eventual bronchial tree prosthesis implantation). Patients are usually in poor general condition and prognosis is unfavorable. This described management improves the patient's comfort of life, rendering possible oral nutrition, and the implementation of chemotherapy.
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References
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- Kaufamn J, Thongsuwan N, Stern E, Karmy-Jones R. Esophageal-pericardial fistula with purulent pericarditis secondary to esophageal carcinoma presenting with tamponade Ann Thorac Surg 2003;75:288-289.[Abstract/Free Full Text]
- Muto M, Ohtsu A, Boku N, Tajiri H, Yoshida S. Streptococcus milleri infection and pericardial abscess associated with esophageal carcinoma: report of two cases Hepatogastroenterology 1999;46:1782-1784.[Medline]
- Cury N, Anderson RS. Pneumopericardium and esophago-pericardial fistula following chronic esophagistis presenting as acute respiratory distress Chest 1974;66:731-733.
- Konttinen MP, Pikaranta PP, Heikkinen LO, Talja MT, Ala-Kulju KV. Esophago-pericardial fistula. A case report and review of the literature. Thorac Cardiovasc Surg 1985;33:341-343.[Medline]
- Luhti F, Groebli Y, Newton A, et al. Cardiac and pericardial fistula associated with esophageal or gastric neoplasms: a literature review Int Surg 2003;88:188-193.[Medline]
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- Alexander EP, Trachiotis GD, Lipman TO, Wadlleigh RG. Evolving management and outcome of esophageal cancer with airway involvement Ann Thor Surg 2001;71:1640-1664.[Abstract/Free Full Text]
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Abstract
Introduction
