Ann Thorac Surg 2011;91:e10-e11. doi:10.1016/j.athoracsur.2010.09.082
© 2011 The Society of Thoracic Surgeons
Case Reports
Gastropericardial Fistula-Induced Pyopneumopericardium After Esophagectomy With Esophagogastrectomy
Won Jung Kim, MDa,
Eun Jeong Choi, MD, PhDa,*,
Yu-Whan Oh, MD, PhDa,
Kwang Taik Kim, MD, PhDb,
Chul Whan Kim, MD, PhDc
a Department of Radiology, Korea University Medical Center, Seoul, South Korea
b Department of Thoracic Surgery, Korea University Medical Center, Seoul, South Korea
c Department of Pathology, Korea University Medical Center, Seoul, South Korea
Accepted for publication September 27, 2010.
* Address correspondence to Dr Choi, Department of Radiology, Korea University College of Medicine, Anam 5-ga, Seongbuk-gu, Seoul, 136-705 South Korea (Email: cadpel2{at}naver.com).
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Abstract
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Gastropericardial fistula is an acquired disorder presenting as an abnormal communication between the stomach and the pericardium, with a rare incidence and extremely high mortality rate. We recently experienced a case of life-threatening gastropericardial fistula occurring as an unusual complication after an esophagectomy with an esophagogastrostomy for esophageal cancer treatment. A 68-year-old man with a history of esophagectomy and esophagogastrostomy using the gastric pedicle for the esophageal cancer 13 years ago, visited the hospital with a complaint of dyspnea for 3 days. Chest roentgenogram, computed tomographic scan, and endoscopy showed a pneumopericardium and huge ulcer with central perforation in the posterior wall of the gastric pedicle.
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Introduction
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Partial esophageal resection and esophagus reconstruction with the gastric pedicle is a surgical operation commonly performed as esophageal cancer treatment. Several complications are associated with this aggressive surgical management, such as anastomosis leak, perforation, and so forth. Gastropericardial fistula is an acquired abnormal communication between the stomach and the pericardium, which is usually associated with several benign, malignant, and traumatic pathology of the esophagus, and it has an extremely high mortality rate [1, 2]. Herein, we report a case of life-threatening gastropericardial fistula as an infrequent complication of an esophagectomy with esophagogastrostomy for esophageal cancer management.
A 68-year-old man visited our hospital with a chief complaint of dyspnea for 3 days. The patient was diagnosed of a squamous cell carcinoma on the mid-esophagus 13 years ago, and he subsequently performed a surgical treatment. The patient underwent transthoracic esophagectomy and esophagogastrostomy, using the gastric pedicle that was brought up into the neck by way of the anterior mediastinum in the parietal space beneath the sternum. After surgery, he did not show any recurrence of esophageal cancer or major complications, except for some illness, such as anastomosis site ulceration, reflux esophagitis, and benign gastric ulcers, which were all successfully treated and resolved.
On admission, laboratory findings revealed his hemoglobin (9.0 g/dL), his white blood cell count (25.8 x 103/µL), and his platelet count (761 x 103/µL). Chest roentgenogram showed pneumopericardium and bilateral pleural effusion (Fig 1). A pneumothorax subsequently developed after a thoracentesis for the evaluation of pleural effusion. A computed tomographic (CT) scan revealed a marked pericardial thickening and air collection within the pericardial space. In particular, a gastric defect in the posterior wall of the gastric pedicle was noted; this abnormal finding was not detected in previous CT scans taken for surveying cancer recurrence after surgery. Endoscopy revealed a huge ulcer with central perforation at the posterior wall of the stomach (Fig 2).
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Fig 2. Endoscopy shows a large circular ulcer with the central perforation of air bubbling in the posterior wall of the mediastinal gastric pedicle 39 cm from the central incisor.
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An emergency operation ensued for surgical correction with a right anterior thoracotomy through the right sixth intercostals space extended over the xiphoid process and careful dissection to expose the gastric tube; a 1.5-cm sized fistulous tract was found between the posterior aspect of the gastric pedicle and pericardium at the level of the xiphoid process. Meanwhile, a yellowish pus like pericardial effusion with food material was observed in the pericardial cavity. The gastric pedicle was removed, and the anterior wall of the pericardium with a 5 cm-diameter was also excised. The pericardial defect was covered with mediastinal fat tissue, and it was sutured in place. Cervical esophagostomy was followed. After a 6-month span of follow-up, the patient recovered from the lethal condition, and colonic interposition surgery was contemplated as a follow-up measure.
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Comment
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Gastropericardial fistula is a rare disease, with an overall mortality rate of more than 50% to 80% [1]. In the cases of the gastropericardial fistula, the position of the stomach is usually intrathoracic, through the hiatus as a hernia or diaphragmatic hernia after laparoscopic surgery for reflux disease, or after an esophagectomy with gastric pedicle pull-up [2, 3]. Peptic ulcers on the upper digestive tract are sometimes followed by perforation, hemorrhage, and fistulous tract formation into the pericardium; this is a rare completing, but it is still possible to occur after intractable peptic ulceration. Intra-abdominal stomach pathology, such as transdiaphragmatic perforation of the gastric cancer or ulcer into the pericardium can also cause gastropericardial fistula [4]. As for our patient, he underwent a transthoracic esophagectomy with esophagogastrostomy using gastric pedicle, and he had a fistulous tract between the gastric pedicle and the pericardium after several bouts of ulcerative events on the upper gut.
Clinically, the gastropericardial fistula presents from asymptomatic to various complaints, such as dyspepsia, progressive epigastric pain, and a referred left shoulder pain probably due to diaphragmatic and pericardial irritation, to a sudden unexpected death secondary to cardiac tamponade. In our case, he complained of dyspnea for 3 days, suggestive of the thickened pericardium and restriction of cardiac circulation being the cause of the symptom. He had no cardiac tamponade thanks to the relatively large fistulous tract preventing from accumulation of a purulent exudate in pericardium, with a probable mechanism of a one-way valve-type mechanism.
Simple chest roentgenogram commonly shows cardiac enlargement, air, or air fluid level in the pericardial cavity. A small amount of methylene blue or water soluble contrast may visualize a fistula tract in contrast roentgenogram [5, 6]. A CT can be performed to confirm whether or not the cause was evident in the contrast roentgenogram. A CT will provide an informative finding of a chest associated with gastropericardial fistula. Endoscopy may be helpful in establishing the diagnosis, but should be used with caution, because excessive air insufflation by the endoscope may exacerbate the cardiac tamponade [7]. For the survival of the patient with gastropericardial fistula, early detection, timely pericardial drainage, and gastrointestinal surgery in an intensive care setting are essential.
In conclusion, we suggest that a follow-up meticulous examination for early detection of an ulcer for a patient with the gastric pedicle esophagectomy and esophagogastrostomy is important, for peptic ulcer perforation can cause gastropericardial fistula, which is a rare but very lethal complication with high rate of the fetal result.
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References
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- Letoquart JP, Fasquel JL, L’Huillier JP, et al. Gastropericardial fistula. Review of the literature apropos of an original case. J Chir (Paris) 1990;127:6-12.[Medline]
- Murthy S, Looney J, Jaklitsch MT. Gastropericardial fistula after laparoscopic surgery for reflux disease N Engl J Med 2002;346:328-332.[Medline]
- Son DK, Kim JK, Chung JS, et al. A case of gastropericardial fistula as a complication after esophagectomy with esophagogastrostomy for esophageal cancer Korean J Gastrointest Endoscj 2004;29:13-16.
- Grandhi TM, Rawlings D, Morran CG. Gastropericardial fistula: a case report and review of literature Emerg Med J 2004;21:644-645.[Free Full Text]
- Michieletto S, Ruol A, Cagol M, et al. Treatment of esophagopericardial fistula following esophagogastroplasty for esophageal caustic stenosis Ann Ital Chir 2007;78:243-246.[Medline]
- Ruano Poblador A, Gay Fernández AM, García Martínez MT, et al. Pneumopericardium caused by gastropericardial fistula Rev Esp Enferm Dig 2007;99:168-171.[Medline]
- Simice P, Zwirewich CV. Gastropericardial fistula complicating benign gastric ulcer: case report Can Assoc Radiol J 2000;51:244-247.[Medline]
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Abstract
Introduction
