Yasmin Khader, MD, Sami Ghazaleh, MD, Kanana Aburayyan, MD, Christian Nehme, MD, Jordan Burlen, MD, Ali Nawras, MD, FACG; University of Toledo Medical Center, Toledo, OH
Introduction: Esophagectomy is the mainstay therapy for esophageal carcinoma. The surgery can be complicated by anastomotic leak, anastomotic stricture, conduit ischemia, recurrent laryngeal nerve injury, and chylothorax. Rarely, a fistula can form between the gastrointestinal tract and the surrounding structures. We describe a case of esophagopericardial fistula following esophagectomy.
Methods: A 50-year-old man presented to the ED with a chest pain of 2-week duration associated with poor appetite, sweating, and chills. He was diagnosed with stage 3 esophageal adenocarcinoma 4 months ago. He had received chemotherapy and radiation before he underwent distal esophagectomy, partial gastrectomy, and J-tube placement 1 month before presentation. His other medical problems included anemia of chronic disease and anxiety. Family history was positive for lung cancer in his mother. He smoked cigarettes but denied alcohol and illicit drug use. Vital signs demonstrated tachycardia with a heart rate of 175 beats per minute and a blood pressure of 93/73 mmHg. Cardiovascular exam showed tachycardia, distant heart sounds, and jugular venous distention (JVD). Chest x-ray showed bilateral pleural effusions with opacities in the lower lungs, suggestive of atelectasis. EKG was significant for sinus tachycardia and troponin was not elevated. Chest computed tomography angiography (CTA) was negative for pulmonary embolism but was significant for pneumomediastinum concerning for anastomotic leak. Esophagram confirmed the presence of an esophagopericardial fistula (Figure 1). The patient was stabilized with IV fluids, antibiotics, and antifungals. A drain was placed into the pericardial space which evacuated blood and partially digested food. Simultaneously, an esophagogastroduodenoscopy (EGD) confirmed the presence of a large esophagopericardial fistula of 25 mm at the gastroesophageal anastomosis site with pericardial draining catheter seen within the esophageal lumen (Figure 2). A fully covered self-expandable metallic esophageal stent was then placed across the gastroesophageal anastomosis site (Figure 3). However, he continued to have persistent leak and eventually underwent a cervical esophagostomy and jejunostomy tube placement. The patient was discharged home in a stable condition. Discussion: Esophagopericardial fistula is a rare complication of esophagectomy with a high mortality rate. Esophageal stenting could be useful as the temporary or definite treatment.
Esophagram showing the esophagopericardial fistula
Esophagogastroduodenoscopy showing esophagopericardial fistula with pericardial draining catheter seen within the esophageal lumen
Esophagogastroduodenoscopy showing esophageal stent in place across the fistula site
Disclosures: Yasmin Khader indicated no relevant financial relationships. Sami Ghazaleh indicated no relevant financial relationships. Kanana Aburayyan indicated no relevant financial relationships. Christian Nehme indicated no relevant financial relationships. Jordan Burlen indicated no relevant financial relationships. Ali Nawras indicated no relevant financial relationships.