Ann Thorac Surg 2009;87:1959. doi:10.1016/j.athoracsur.2008.09.027
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
A Case of Severe Heartburn
Subroto Paul, MD*,
Nasser K. Altorki, MD,
Brendon M. Stiles, MD,
Jeffrey L. Port, MD,
Paul C. Lee, MD
Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
* Address correspondence to Dr Paul, Cardiothoracic Surgery, Weill Cornell Medical College, 525 E 68th St, M404, 4th Floor Greenberg Pavilion, New York, NY 10065 (Email: pas2022{at}med.cornell.edu).
A 71-year-old man being treated for T3 N1 (stage III) esophageal cancer with chemotherapy as part of a definitive chemoradiation protocol presented after a motor vehicle accident. A trauma survey chest computed tomography scan revealed a moderate pericardial effusion and pneumopericardium (Fig 1A). An echocardiogram confirmed these findings with evidence of tamponade.
Before any intervention, the patient sustained a fibrillatory arrest, but was defibrillated and resuscitated into normal sinus rhythm. An emergency subxiphoid window drained frank purulence. The patient was neurologically intact at extubation but in atrial fibrillation. An esophagram revealed an esophagopericardial fistula (Fig 1B), which was confirmed on endoscopy (Fig 1C; * = Site of fistula). A covered esophageal stent (Alveolus, Charlotte, NC) was placed across the fistula, and a subsequent esophagram revealed no contrast extravasation into the pericardium.
After the procedure, the patient converted into normal sinus rhythm and was discharged tolerating a regular diet and not requiring antibiotics. Malignant esophagopericardial fistulas are rare complications of esophageal cancer. Covered esophageal stents can effectively palliate these patients.
