CASE REPORT BHARAT ET AL ATRIOGASTRIC FISTULA AFTER TRANSHIATAL ESOPHAGECTOMY
References 1. Patterson TF. Aspergillus species. In: Mandel GL, Bennet JE, Dolin RE (eds). Principles and practice of infectious diseases. Philadelphia: Elsevier, 2010. p. 3241–55. 2. Chakrabarti A, Chatterjee SS, Das A, Shivaprakash MR. Invasive aspergillosis in developing countries. Med Mycol 2010;49(Suppl 1):S35–47. 3. Segal BH. Aspergillosis. N Engl J Med 2009;360:1870–84. 4. Stevens DA, Melikian GL. Aspergillosis in the “nonimmunocompromised” host. Immunol Invest 2011;40:751–66. 5. Zmeili OS, Soubani AO. Pulmonary aspergillosis: a clinical update. QJM 2007;100:317–34. 6. Ahmad M, Weinstein AJ, Hughes JA, Cosgrove DE. Granulomatous mediastinitis due to Aspergillus flavus in a nonimmunosuppressed patient. Am J Med 1981;70:887–90. 7. Brooks M, Royse C, Eisen D, et al. An accidental mass. Lancet 2011;377:1806. 8. Shakoor MT, Ayub S, Ayub Z, Mahmood F. Fulminant invasive aspergillosis of the mediastinum in an immunocompetent host: a case report. J Med Case Rep 2012;6:311. 9. Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2008;46: 327–60.
Successful Repair of Benign Left Atriogastric Fistula After Transhiatal Esophagectomy Ankit Bharat, MD, Ralph Damiano, MD, and G. Alexander Patterson, MD Division of Thoracic Surgery, Northwestern University, Chicago, Illinois; Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
Benign gastrocardiac fistula is a rare complication following esophagectomy that can occur when the gastric tube is placed in the retrosternal space. We describe a benign fistula between the left atrium and the gastric conduit following transhiatal esophagectomy. The surgical technique that was used for successfully repair is also discussed. (Ann Thorac Surg 2014;98:1475–7) Ó 2014 by The Society of Thoracic Surgeons
enign gastroatrial fistula is a rare complication following esophagectomy, with only about six cases reported in the literature [1–3]. It appears to be more common after retrosternal gastric tube reconstruction. Ischemia and gastric acid stasis in the dependent portion of the conduit are speculated to lead to the fistulization with the right ventricle that lies immediately posterior. In case of transhiatal esophagectomy, the conduit is in the posterior mediastinum and is less likely to fistulize to the
B
Accepted for publication Nov 25, 2013. Address correspondence to Dr Patterson, 660 S Euclid Ave, St. Louis, MO 63108; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
1475
heart. Nevertheless, the lesser curvature staple line lies directly posterior to the left atrium. The case here demonstrates that such fistulae can occur even after transhiatal esophagectomy, and prompt surgical repair is required; otherwise, they are fatal. A 56-year old male patient underwent neoadjuvant chemoradiation followed by transhiatal esophagectomy 3.5 years ago for T3N1M0 distal adenocarcinoma. Of note, the lesser curvature staple line was oversewn using a 3-0 silk suture as part of the procedure. An esophagram on day 6 was normal. The patient was discharged on a full liquid diet and jejunal tube feeding for 4 weeks. Fourweek follow-up was unremarkable, and his diet was advanced. Complete pathologic response was noted to the neoadjuvant chemoradiation, with no residual tumor in the specimen. Surveillance CT at 1 year demonstrated four liver metastases. He received chemotherapy for 6 months. A repeated CT scan revealed regression of the liver lesions. He underwent radiofrequency ablation of the liver metastases. Chemotherapy was continued, and surveillance PET-CT scan 1 year later showed no uptake in the liver lesions and no other metastasis. Three and a half years after the initial esophagectomy, the patient was admitted to the hospital with fever and streptococcal bacteremia. The next day, he developed massive hematemesis that prompted an urgent upper endoscopy. A large amount of blood was noted in the conduit along with an ulcer with adherent clot at the base. The ulcer was present along the lesser curvature staple line. It was recognized that the right gastric artery was ligated at the time of initial surgery and no major vascular pedicle should be present along the lesser curvature, raising the suspicion of a cardiogastric fistula as the cause of the bleeding. A CT scan confirmed the presence of left atrioconduit fistula along the lesser curvature staple line (Fig 1). The patient underwent a median sternotomy and repair of the fistula on cardiopulmonary bypass. After the sternotomy, a pericardial flap was created reflecting the anterior pericardium and the fat pad. Cardiopulmonary bypass was initiated, and cardiac arrest was achieved through antegrade cardioplegia. This was done with minimal manipulation to prevent exsanguination into the conduit or air embolism to the left atrium. The Sonderguard’s grove was dissected, and left atrium was opened. A 6-mm ulcer was found in the posterior midline of the left atrium just inferior to the right inferior pulmonary vein (Fig 2A). The left atrium was thoroughly irrigated, and the ulcer was closed in two layers using 3-0 Prolene suture. Fairly generous bites of the endothelium and myocardium were taken to achieve good endothelial approximation. Subsequently, the left atrium was closed in standard fashion, and a left ventricular vent was left to facilitate closure of the gastric conduit ulcer with heart beating, but empty. Aortic cross clamp was removed after placing a root vent, and the heart was retracted superiorly (Fig 2B), exposing the gastric conduit. The posterior pericardium 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.11.083
FEATURE ARTICLES
Ann Thorac Surg 2014;98:1475–7
1476
CASE REPORT BHARAT ET AL ATRIOGASTRIC FISTULA AFTER TRANSHIATAL ESOPHAGECTOMY
Ann Thorac Surg 2014;98:1475–7
Fig 1. CT image of the chest. (A) Extravasation from the back of left atrium just caudal to the inferior pulmonary veins shown by a red arrow. (B) Air seen along with lesser curvature staple line on the corresponding to the gastric ulcer also shown by a red arrow.
FEATURE ARTICLES
was incised circumferentially, leaving a 3–4-cm rim around the conduit ulcer. Adhesions of the conduit to posterior mediastinum were released in this region. The edges of the ulcer were freshened, and good bleeding was noted from the mucosa. The ulcer was then closed using interrupted 2-0 silk suture (Fig 2C). Next, the anterior pericardial flap was brought down to the repair and interposed between the conduit and the heart. Patient was weaned from bypass, and the chest was closed in standard fashion. On day 2, the patient received a feeding jejunostomy tube for early nutrition. Esophagram on day 7 showed no evidence of leak (Fig 3), and he was discharged on a liquid diet with night-time tube feedings. At 4 weeks, he was advanced to a regular diet. Endoscopy performed at 8 weeks showed complete resolution of the ulcer. Chemotherapy regimen was resumed, and he remained disease free 9 months after surgery.
Comment Fistulae with pericardium or right ventricle are particularly associated with retrosternal route of gastric tube [1] and require a high degree of suspicion. As evident here, they can occur even when the conduit is in the posterior mediastinum. Cardiogastric fistulae following
esophagectomy are usually lethal [4, 5]. In our patient, there were several favorable factors. First, the patient was in the hospital when hematemesis occurred, leading to prompt resuscitation, endoscopy, and surgical repair. Second, during endoscopy, a fistula with the heart was correctly suspected, and the ulcer was intentionally not cauterized despite having the stigmata of recent bleed. Third, the patient was in excellent health despite having received chemotherapy. The etiology of the ulcer, however, remains unclear. The patient never demonstrated a leak from the conduit either clinically or on the esophagram following initial esophagectomy. The anastomosis was also found to be intact on present endoscopy. Test results for Helicobacter pylori were negative. Because of the location of the ulcer at the lesser curvature, ischemia is an important consideration. In addition, the patient could have developed a staple line breakdown from chemotherapy, although that is difficult to prove. Alternatively, gastric acid production, despite vagotomy, and stasis could have contributed. Because of the communication of the conduit with the left atrium and concerns for air embolism or massive exsanguination, we chose sternotomy; this allowed us to cross-clamp the heart with minimal manipulation. There were other important aspects of the repair. First, we believed that it was important to close the atrial side of
Fig 2. Intraoperative images. (A) The left atrium is opened following aortic cross clamp. The fistula is visualized on the back wall of the atrium. Atrial defect was closed in two layers using a running 3-0 Prolene suture. (B) The heart is retracted superiorly, revealing a gastric conduit ulcer. The defect appears larger because the edges have been debrided. (C) Gastric defect is closed using an interrupted 2-0 silk suture.
Ann Thorac Surg 2014;98:1475–7
CASE REPORT BHARAT ET AL ATRIOGASTRIC FISTULA AFTER TRANSHIATAL ESOPHAGECTOMY
1477
the fistula from inside, because good endothelial approximation is key to proper healing. Second, we think it is important to interpose a vascularized pedicle, the pericardial flap in this case, to separate the repair between conduit and the atrium. Finally, the decision to resect the conduit or primarily repair was a matter of debate. In such a situation, the viability of the tissue should be assessed and weighed against the morbidity of resecting the entire conduit. We debrided the ulcer edges and were satisfied with the viability and vascularity of the mucosa. In addition, the closure was completely tension free after mobilization the edges of the conduit; therefore, we elected to primarily close it. To summarize, we report an extremely rare complication of left atriogastric fistula and demonstrate that it can occur even after transhiatal esophagectomy. A high degree of suspicion and prompt surgical repair are crucial to treat this lethal complication.
Fig 3. Postoperative esophagram revealing no evidence of leak.
1. Pentiak P, Seder CW, Chmielewski GW, Welsh RJ. Benign post-esophagectomy gastrocardiac fistula. Interact Cardiovasc Thorac Surg 2011;13:447–9. 2. Schouten van der Velden AP, Ruers TJ, Bonenkamp JJ. A cardiogastric fistula after gastric tube interposition. A case report and review of literature. J Surg Oncol 2007;95:79–82. 3. Coelho JC, Moraes LM, Greca FH, Artigas GV. Gastroatrial fistula following esophagectomy with esophagogastrostomy. Int Surg 1989;74:107–8. 4. Begin LR, Sheiner NM. Anastomotic ulcer-induced aortoenteric fistula after esophagogastroplasty. Ann Thorac Surg 1992;54:564–5. 5. Brynjolfsson G, Kania R, Bekeris L. Gastroesophageal cardiac fistula due to perforation of an esophagogastric anastomotic ulcer into the left atrium. Hum Pathol 1980;11:677–9.
FEATURE ARTICLES
References
References 1. Patterson TF. Aspergillus species. In: Mandel GL, Bennet JE, Dolin RE (eds). Principles and practice of infectious diseases. Philadelphia: Elsevier, 2010. p. 3241–55. 2. Chakrabarti A, Chatterjee SS, Das A, Shivaprakash MR. Invasive aspergillosis in developing countries. Med Mycol 2010;49(Suppl 1):S35–47. 3. Segal BH. Aspergillosis. N Engl J Med 2009;360:1870–84. 4. Stevens DA, Melikian GL. Aspergillosis in the “nonimmunocompromised” host. Immunol Invest 2011;40:751–66. 5. Zmeili OS, Soubani AO. Pulmonary aspergillosis: a clinical update. QJM 2007;100:317–34. 6. Ahmad M, Weinstein AJ, Hughes JA, Cosgrove DE. Granulomatous mediastinitis due to Aspergillus flavus in a nonimmunosuppressed patient. Am J Med 1981;70:887–90. 7. Brooks M, Royse C, Eisen D, et al. An accidental mass. Lancet 2011;377:1806. 8. Shakoor MT, Ayub S, Ayub Z, Mahmood F. Fulminant invasive aspergillosis of the mediastinum in an immunocompetent host: a case report. J Med Case Rep 2012;6:311. 9. Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2008;46: 327–60.
Successful Repair of Benign Left Atriogastric Fistula After Transhiatal Esophagectomy Ankit Bharat, MD, Ralph Damiano, MD, and G. Alexander Patterson, MD Division of Thoracic Surgery, Northwestern University, Chicago, Illinois; Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
Benign gastrocardiac fistula is a rare complication following esophagectomy that can occur when the gastric tube is placed in the retrosternal space. We describe a benign fistula between the left atrium and the gastric conduit following transhiatal esophagectomy. The surgical technique that was used for successfully repair is also discussed. (Ann Thorac Surg 2014;98:1475–7) Ó 2014 by The Society of Thoracic Surgeons
enign gastroatrial fistula is a rare complication following esophagectomy, with only about six cases reported in the literature [1–3]. It appears to be more common after retrosternal gastric tube reconstruction. Ischemia and gastric acid stasis in the dependent portion of the conduit are speculated to lead to the fistulization with the right ventricle that lies immediately posterior. In case of transhiatal esophagectomy, the conduit is in the posterior mediastinum and is less likely to fistulize to the
B
Accepted for publication Nov 25, 2013. Address correspondence to Dr Patterson, 660 S Euclid Ave, St. Louis, MO 63108; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
1475
heart. Nevertheless, the lesser curvature staple line lies directly posterior to the left atrium. The case here demonstrates that such fistulae can occur even after transhiatal esophagectomy, and prompt surgical repair is required; otherwise, they are fatal. A 56-year old male patient underwent neoadjuvant chemoradiation followed by transhiatal esophagectomy 3.5 years ago for T3N1M0 distal adenocarcinoma. Of note, the lesser curvature staple line was oversewn using a 3-0 silk suture as part of the procedure. An esophagram on day 6 was normal. The patient was discharged on a full liquid diet and jejunal tube feeding for 4 weeks. Fourweek follow-up was unremarkable, and his diet was advanced. Complete pathologic response was noted to the neoadjuvant chemoradiation, with no residual tumor in the specimen. Surveillance CT at 1 year demonstrated four liver metastases. He received chemotherapy for 6 months. A repeated CT scan revealed regression of the liver lesions. He underwent radiofrequency ablation of the liver metastases. Chemotherapy was continued, and surveillance PET-CT scan 1 year later showed no uptake in the liver lesions and no other metastasis. Three and a half years after the initial esophagectomy, the patient was admitted to the hospital with fever and streptococcal bacteremia. The next day, he developed massive hematemesis that prompted an urgent upper endoscopy. A large amount of blood was noted in the conduit along with an ulcer with adherent clot at the base. The ulcer was present along the lesser curvature staple line. It was recognized that the right gastric artery was ligated at the time of initial surgery and no major vascular pedicle should be present along the lesser curvature, raising the suspicion of a cardiogastric fistula as the cause of the bleeding. A CT scan confirmed the presence of left atrioconduit fistula along the lesser curvature staple line (Fig 1). The patient underwent a median sternotomy and repair of the fistula on cardiopulmonary bypass. After the sternotomy, a pericardial flap was created reflecting the anterior pericardium and the fat pad. Cardiopulmonary bypass was initiated, and cardiac arrest was achieved through antegrade cardioplegia. This was done with minimal manipulation to prevent exsanguination into the conduit or air embolism to the left atrium. The Sonderguard’s grove was dissected, and left atrium was opened. A 6-mm ulcer was found in the posterior midline of the left atrium just inferior to the right inferior pulmonary vein (Fig 2A). The left atrium was thoroughly irrigated, and the ulcer was closed in two layers using 3-0 Prolene suture. Fairly generous bites of the endothelium and myocardium were taken to achieve good endothelial approximation. Subsequently, the left atrium was closed in standard fashion, and a left ventricular vent was left to facilitate closure of the gastric conduit ulcer with heart beating, but empty. Aortic cross clamp was removed after placing a root vent, and the heart was retracted superiorly (Fig 2B), exposing the gastric conduit. The posterior pericardium 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.11.083
FEATURE ARTICLES
Ann Thorac Surg 2014;98:1475–7
1476
CASE REPORT BHARAT ET AL ATRIOGASTRIC FISTULA AFTER TRANSHIATAL ESOPHAGECTOMY
Ann Thorac Surg 2014;98:1475–7
Fig 1. CT image of the chest. (A) Extravasation from the back of left atrium just caudal to the inferior pulmonary veins shown by a red arrow. (B) Air seen along with lesser curvature staple line on the corresponding to the gastric ulcer also shown by a red arrow.
FEATURE ARTICLES
was incised circumferentially, leaving a 3–4-cm rim around the conduit ulcer. Adhesions of the conduit to posterior mediastinum were released in this region. The edges of the ulcer were freshened, and good bleeding was noted from the mucosa. The ulcer was then closed using interrupted 2-0 silk suture (Fig 2C). Next, the anterior pericardial flap was brought down to the repair and interposed between the conduit and the heart. Patient was weaned from bypass, and the chest was closed in standard fashion. On day 2, the patient received a feeding jejunostomy tube for early nutrition. Esophagram on day 7 showed no evidence of leak (Fig 3), and he was discharged on a liquid diet with night-time tube feedings. At 4 weeks, he was advanced to a regular diet. Endoscopy performed at 8 weeks showed complete resolution of the ulcer. Chemotherapy regimen was resumed, and he remained disease free 9 months after surgery.
Comment Fistulae with pericardium or right ventricle are particularly associated with retrosternal route of gastric tube [1] and require a high degree of suspicion. As evident here, they can occur even when the conduit is in the posterior mediastinum. Cardiogastric fistulae following
esophagectomy are usually lethal [4, 5]. In our patient, there were several favorable factors. First, the patient was in the hospital when hematemesis occurred, leading to prompt resuscitation, endoscopy, and surgical repair. Second, during endoscopy, a fistula with the heart was correctly suspected, and the ulcer was intentionally not cauterized despite having the stigmata of recent bleed. Third, the patient was in excellent health despite having received chemotherapy. The etiology of the ulcer, however, remains unclear. The patient never demonstrated a leak from the conduit either clinically or on the esophagram following initial esophagectomy. The anastomosis was also found to be intact on present endoscopy. Test results for Helicobacter pylori were negative. Because of the location of the ulcer at the lesser curvature, ischemia is an important consideration. In addition, the patient could have developed a staple line breakdown from chemotherapy, although that is difficult to prove. Alternatively, gastric acid production, despite vagotomy, and stasis could have contributed. Because of the communication of the conduit with the left atrium and concerns for air embolism or massive exsanguination, we chose sternotomy; this allowed us to cross-clamp the heart with minimal manipulation. There were other important aspects of the repair. First, we believed that it was important to close the atrial side of
Fig 2. Intraoperative images. (A) The left atrium is opened following aortic cross clamp. The fistula is visualized on the back wall of the atrium. Atrial defect was closed in two layers using a running 3-0 Prolene suture. (B) The heart is retracted superiorly, revealing a gastric conduit ulcer. The defect appears larger because the edges have been debrided. (C) Gastric defect is closed using an interrupted 2-0 silk suture.
Ann Thorac Surg 2014;98:1475–7
CASE REPORT BHARAT ET AL ATRIOGASTRIC FISTULA AFTER TRANSHIATAL ESOPHAGECTOMY
1477
the fistula from inside, because good endothelial approximation is key to proper healing. Second, we think it is important to interpose a vascularized pedicle, the pericardial flap in this case, to separate the repair between conduit and the atrium. Finally, the decision to resect the conduit or primarily repair was a matter of debate. In such a situation, the viability of the tissue should be assessed and weighed against the morbidity of resecting the entire conduit. We debrided the ulcer edges and were satisfied with the viability and vascularity of the mucosa. In addition, the closure was completely tension free after mobilization the edges of the conduit; therefore, we elected to primarily close it. To summarize, we report an extremely rare complication of left atriogastric fistula and demonstrate that it can occur even after transhiatal esophagectomy. A high degree of suspicion and prompt surgical repair are crucial to treat this lethal complication.
Fig 3. Postoperative esophagram revealing no evidence of leak.
1. Pentiak P, Seder CW, Chmielewski GW, Welsh RJ. Benign post-esophagectomy gastrocardiac fistula. Interact Cardiovasc Thorac Surg 2011;13:447–9. 2. Schouten van der Velden AP, Ruers TJ, Bonenkamp JJ. A cardiogastric fistula after gastric tube interposition. A case report and review of literature. J Surg Oncol 2007;95:79–82. 3. Coelho JC, Moraes LM, Greca FH, Artigas GV. Gastroatrial fistula following esophagectomy with esophagogastrostomy. Int Surg 1989;74:107–8. 4. Begin LR, Sheiner NM. Anastomotic ulcer-induced aortoenteric fistula after esophagogastroplasty. Ann Thorac Surg 1992;54:564–5. 5. Brynjolfsson G, Kania R, Bekeris L. Gastroesophageal cardiac fistula due to perforation of an esophagogastric anastomotic ulcer into the left atrium. Hum Pathol 1980;11:677–9.
FEATURE ARTICLES
References
