- Email: [email protected]
Esophageal-pericardial fistula with purulent pericarditis secondary to esophageal carcinoma presenting with tamponade
288
CASE REPORT KAUFMAN ET AL ESOPHAGEAL-PERICARDIAL FISTULA SECONDARY TO ESOPHAGEAL CARCINOMA
Comment
CASE REPORTS
Pump pocket infection as seen in our case may be secondary to blood stream infection as well as primary wound contamination. Tjan and associates [3] described 3 patients who had necrosis of the abdominal or thoracic wall uncovering part of the device. Their cases required, as did our case, multiple surgical revisions after the LVAS implantation for bleeding complications. The local hematoma in the pocket may also be important as a focus of infection. Careful use of sterile techniques and meticulous hemostasis during the operation may be the best prophylaxis for the pocket infection. Intraperitoneal insertion of the device is regaining attention because it is associated with a lower incidence of infectious complications but it may result in serious gut complications such as intestinal perforation. There has been no effective treatment for severe device pocket infection except to follow the general rule of treating infected prosthetic materials, ie, removing the device and performing the cardiac transplantation [2– 4]. To realize the permanent use of LVAS, however, an effective treatment for this problem is mandatory. We utilized a pedicled flap of greater omentum, which is widely used to manage infection of prosthetic materials including vascular grafts in thoracic surgery [6]. Its usefulness for controlling infection supposedly depends on the increased blood supply to infected areas, thus intensifying inflammatory cell infiltration and increasing tissue concentration of antibiotics. The pedicled flap also absorbs necrotic tissue and fluid and fills dead space, thus reducing the possibility of regrowth of residual bacteria. Although there were some difficulties in making the omental flap through the limited incision behind the LVAS pump, the careful surgical procedure made it possible to create a flap wide enough to fill the device circumferentially. In summary surgical drainage, local irrigation, and omental transposition into the device pocket are effective treatment options to control the pocket infection. This case implies a prophylactic use of the omental flap in the pump pocket located in the abdominal wall during the implant operation when a long waiting time is expected or a device is implanted as a destination therapy.
References 1. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435–43. 2. McCarthy PM, Schmitt SK, Vargo RL, Gordon S, Keys TF, Hobbs RE. Implantable LVAD infection. Implication for permanent use of the device. Ann Thorac Surg 1996;61:359 –65. 3. Tjan TDT, Asfour B, Hammel D, Schmidt C, Scheld HH, Schmid C. Wound complications after left ventricular assist device implantation. Ann Thorac Surg 2000;70:538 –41. 4. Herrmann M, Weyand M, Greshake B, et al. Left ventricular assist device infection is associated with increased mortality but is not a contraindication to transplantation. Circulation 1997;95:814 –7. © 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2003;75:288 –9
5. Gordon SM, Schmitt SK, Jacobs M, et al. Nosocomial bloodstream infections in patients with implantable left ventricular assist devices. Ann Thorac Surg 2001;72:725–30. 6. Luciani N, Lapenna E, Bonis MD, Possati GF. Mediastinitis following graft replacement of the ascending aorta: conservative approach by omental transposition. Eur J Cardiothorac Surg 2001;20:418 –20.
Esophageal-Pericardial Fistula With Purulent Pericarditis Secondary to Esophageal Carcinoma Presenting With Tamponade Jeddediah Kaufman, MD, Nisa Thongsuwan, MD, Eric Stern, MD, and Riyad Karmy-Jones, MD Departments of Surgery and Radiology, University of Washington, Seattle, Washington
A case of esophago-pericardial fistula secondary to esophageal carcinoma causing pericardial effusion and tamponade is presented. Palliation can be achieved effectively by limited thoracotomy, pericardial resection and drainage, and in selected cases esophageal stenting. (Ann Thorac Surg 2003;75:288 –9) © 2003 by The Society of Thoracic Surgeons
P
ericardial effusion in the setting of esophageal carcinoma is most commonly related to radiation and/or chemotherapy, rarely to esophago-pericardial fistula [1]. We report a case of a 47-year-old male with known esophageal carcinoma and an esophagopericardial fistula causing cardiac tamponade requiring emergency surgical treatment. A 47-year-old male presented with sharp chest pain radiating to the left neck, right chest, and down both arms after smoking crack cocaine. He was diaphoretic and tachypneic. Vital signs at presentation were blood pressure of 59/42 mm Hg, pulse of 76, temperature of 34.0°C and oxygen saturation of 94%. His medical history was significant for metastatic esophageal carcinoma with liver involvement documented by computed tomography 3 months prior to presentation. Cardiac enzymes ruledout myocardial ischemia, and a spiral computed tomographic scan of the chest was obtained to evaluate pulmonary embolus, which revealed a moderate right pericardial effusion with air-fluid levels (Fig 1A). A fistula
Accepted for publication July 31, 2002. Address reprint requests to Dr Karmy-Jones, Division of Thoracic Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104; e-mail: [email protected].
0003-4975/03/$30.00 PII S0003-4975(02)04168-1
Ann Thorac Surg 2003;75:288 –9
CASE REPORT KAUFMAN ET AL ESOPHAGEAL-PERICARDIAL FISTULA SECONDARY TO ESOPHAGEAL CARCINOMA
289
tropic support. However, the patient then refused an esophageal stent placement opting for comfort measures only. He died 7 days later. No malignant cells were identified. Cultures grew Streptococcus milleri and alpha hemolytic Streptococcus.
Fig 1. Computed tomographic scans of chest (lung windows) demonstrating (A) air fluid levels within pericardial sac (arrows) and (B) small fistula (long arrows) between esophagus (short arrow) and small air collection within the pericardium.
from the esophagus to the pericardium at the superior margin of the right ventricle was seen with air tracking into the pericardial sac (Figure 1B). The patient initially refused any invasive intervention. Initially fluid responsive, within 24 hours he required dopamine infusion and fluid resuscitation. During this period the patient changed his mind about interventions. Because echocardiography demonstrated moderate loculations, open drainage was required. A limited left anterolateral non-rib spreading thoracotomy was performed in the fifth intercostal space. The pericardium was tense and upon entering the sac, purulent yellow fluid under considerable pressure began draining into the chest. An increase in systolic blood pressure from 70 mm Hg to 110 mm Hg occurred immediately. After drainage, a 4-cm by 5-cm portion was excised and multiple adhesions taken down. A 24-French chest tube was used to drain the pericardial sac. The patient tolerated the operation well, requiring no further volume or ino-
There are three cases of esophago-pericardial fistulas secondary to esophageal carcinoma reported in the literature [2– 4]. More often such effusions are caused by other malignancies [1, 5]. Because of extensive adhesions, percutaneous drainage or subxiphoid approaches are often insufficient. Anterior thoracotomy with a minimal or non-rib spreading technique provides excellent exposure, ability to resect a large amount of pericardium, perform complete debridement, and avoids pain from rib spreading. In addition, the risk of sternal infection is avoided. Surgical excision or ablation of the fistula is possible and the treatment of choice for nonmalignant fistula. When curative therapy is not possible, this approach also provides the patient minimal morbidity, while resumption of oral intake and faster recuperation. A series of 29 esophagopericardial fistulas, due to causes other than esophageal carcinoma, was reported in 1985 and concluded that surgical drainage of the effusion should occur first with elective operative closure of the fistula second [6]. A case of malignant esophagopericardial fistula resulting in tamponade treated by pericardial drainage followed by esophageal stent was reported in 1999. The perimyocarditis quickly resolved and the patient tolerated oral intake until his death 6 weeks later [2]. Patients with esophagopericardial fistulae can undergo effective palliation by pericardial drainage and subsequent esophageal stenting. If loculations are suspected based on radiographic or echocardiographic findings, a minimal anteriolateral, non-rib spreading thoracotomy will allow debridement and drainage with minimal pain. Further treatment with esophageal stenting and antibiotics can then help these patients regain oral intake and quality of life.
References 1. Renshaw AA, Nappi D, Sugarbaker DJ, Swanson S. Effusion cytology of esophageal carcinoma. Cancer 1997;81:365–372. 2. Kohl O, Schaffer R, Doppl W. [Purulent pericarditis as an initial manifestation of esophageal carcinoma]. Dtsch Med Wochenschr 1999;124:381–385. 3. Furak J, Olah T, Szendrenyi V, Horvath OP, Balogh A. [Esophago-pericardial fistula caused by recurrent esophageal tumor]. Magy Seb 1999;52:89 –91. 4. Navarro P, Heras M, Miro JM, Mateu M. [Cardiac tamponade as the first manifestation of carcinoma of the esophagus]. Med Clin (Barc) 1992;98:661–662. 5. Abiko M, Ohizumi H, Naruke Y, et al. [A case of lung cancer (small cell carcinoma) occurring esophago-pericardial fistula and purulent pericarditis]. Kyobu Geka 1999;52:969 –971. 6. Konttinen MP, Pitkaranta PP, Heikkinen LO, Talja MT, AlaKulju KV. Esophago-pericardial fistula. A case report and review of the literature. Thorac Cardiovasc Surg 1985;33:341– 343.
CASE REPORTS
Comment
CASE REPORT KAUFMAN ET AL ESOPHAGEAL-PERICARDIAL FISTULA SECONDARY TO ESOPHAGEAL CARCINOMA
Comment
CASE REPORTS
Pump pocket infection as seen in our case may be secondary to blood stream infection as well as primary wound contamination. Tjan and associates [3] described 3 patients who had necrosis of the abdominal or thoracic wall uncovering part of the device. Their cases required, as did our case, multiple surgical revisions after the LVAS implantation for bleeding complications. The local hematoma in the pocket may also be important as a focus of infection. Careful use of sterile techniques and meticulous hemostasis during the operation may be the best prophylaxis for the pocket infection. Intraperitoneal insertion of the device is regaining attention because it is associated with a lower incidence of infectious complications but it may result in serious gut complications such as intestinal perforation. There has been no effective treatment for severe device pocket infection except to follow the general rule of treating infected prosthetic materials, ie, removing the device and performing the cardiac transplantation [2– 4]. To realize the permanent use of LVAS, however, an effective treatment for this problem is mandatory. We utilized a pedicled flap of greater omentum, which is widely used to manage infection of prosthetic materials including vascular grafts in thoracic surgery [6]. Its usefulness for controlling infection supposedly depends on the increased blood supply to infected areas, thus intensifying inflammatory cell infiltration and increasing tissue concentration of antibiotics. The pedicled flap also absorbs necrotic tissue and fluid and fills dead space, thus reducing the possibility of regrowth of residual bacteria. Although there were some difficulties in making the omental flap through the limited incision behind the LVAS pump, the careful surgical procedure made it possible to create a flap wide enough to fill the device circumferentially. In summary surgical drainage, local irrigation, and omental transposition into the device pocket are effective treatment options to control the pocket infection. This case implies a prophylactic use of the omental flap in the pump pocket located in the abdominal wall during the implant operation when a long waiting time is expected or a device is implanted as a destination therapy.
References 1. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001;345:1435–43. 2. McCarthy PM, Schmitt SK, Vargo RL, Gordon S, Keys TF, Hobbs RE. Implantable LVAD infection. Implication for permanent use of the device. Ann Thorac Surg 1996;61:359 –65. 3. Tjan TDT, Asfour B, Hammel D, Schmidt C, Scheld HH, Schmid C. Wound complications after left ventricular assist device implantation. Ann Thorac Surg 2000;70:538 –41. 4. Herrmann M, Weyand M, Greshake B, et al. Left ventricular assist device infection is associated with increased mortality but is not a contraindication to transplantation. Circulation 1997;95:814 –7. © 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2003;75:288 –9
5. Gordon SM, Schmitt SK, Jacobs M, et al. Nosocomial bloodstream infections in patients with implantable left ventricular assist devices. Ann Thorac Surg 2001;72:725–30. 6. Luciani N, Lapenna E, Bonis MD, Possati GF. Mediastinitis following graft replacement of the ascending aorta: conservative approach by omental transposition. Eur J Cardiothorac Surg 2001;20:418 –20.
Esophageal-Pericardial Fistula With Purulent Pericarditis Secondary to Esophageal Carcinoma Presenting With Tamponade Jeddediah Kaufman, MD, Nisa Thongsuwan, MD, Eric Stern, MD, and Riyad Karmy-Jones, MD Departments of Surgery and Radiology, University of Washington, Seattle, Washington
A case of esophago-pericardial fistula secondary to esophageal carcinoma causing pericardial effusion and tamponade is presented. Palliation can be achieved effectively by limited thoracotomy, pericardial resection and drainage, and in selected cases esophageal stenting. (Ann Thorac Surg 2003;75:288 –9) © 2003 by The Society of Thoracic Surgeons
P
ericardial effusion in the setting of esophageal carcinoma is most commonly related to radiation and/or chemotherapy, rarely to esophago-pericardial fistula [1]. We report a case of a 47-year-old male with known esophageal carcinoma and an esophagopericardial fistula causing cardiac tamponade requiring emergency surgical treatment. A 47-year-old male presented with sharp chest pain radiating to the left neck, right chest, and down both arms after smoking crack cocaine. He was diaphoretic and tachypneic. Vital signs at presentation were blood pressure of 59/42 mm Hg, pulse of 76, temperature of 34.0°C and oxygen saturation of 94%. His medical history was significant for metastatic esophageal carcinoma with liver involvement documented by computed tomography 3 months prior to presentation. Cardiac enzymes ruledout myocardial ischemia, and a spiral computed tomographic scan of the chest was obtained to evaluate pulmonary embolus, which revealed a moderate right pericardial effusion with air-fluid levels (Fig 1A). A fistula
Accepted for publication July 31, 2002. Address reprint requests to Dr Karmy-Jones, Division of Thoracic Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104; e-mail: [email protected].
0003-4975/03/$30.00 PII S0003-4975(02)04168-1
Ann Thorac Surg 2003;75:288 –9
CASE REPORT KAUFMAN ET AL ESOPHAGEAL-PERICARDIAL FISTULA SECONDARY TO ESOPHAGEAL CARCINOMA
289
tropic support. However, the patient then refused an esophageal stent placement opting for comfort measures only. He died 7 days later. No malignant cells were identified. Cultures grew Streptococcus milleri and alpha hemolytic Streptococcus.
Fig 1. Computed tomographic scans of chest (lung windows) demonstrating (A) air fluid levels within pericardial sac (arrows) and (B) small fistula (long arrows) between esophagus (short arrow) and small air collection within the pericardium.
from the esophagus to the pericardium at the superior margin of the right ventricle was seen with air tracking into the pericardial sac (Figure 1B). The patient initially refused any invasive intervention. Initially fluid responsive, within 24 hours he required dopamine infusion and fluid resuscitation. During this period the patient changed his mind about interventions. Because echocardiography demonstrated moderate loculations, open drainage was required. A limited left anterolateral non-rib spreading thoracotomy was performed in the fifth intercostal space. The pericardium was tense and upon entering the sac, purulent yellow fluid under considerable pressure began draining into the chest. An increase in systolic blood pressure from 70 mm Hg to 110 mm Hg occurred immediately. After drainage, a 4-cm by 5-cm portion was excised and multiple adhesions taken down. A 24-French chest tube was used to drain the pericardial sac. The patient tolerated the operation well, requiring no further volume or ino-
There are three cases of esophago-pericardial fistulas secondary to esophageal carcinoma reported in the literature [2– 4]. More often such effusions are caused by other malignancies [1, 5]. Because of extensive adhesions, percutaneous drainage or subxiphoid approaches are often insufficient. Anterior thoracotomy with a minimal or non-rib spreading technique provides excellent exposure, ability to resect a large amount of pericardium, perform complete debridement, and avoids pain from rib spreading. In addition, the risk of sternal infection is avoided. Surgical excision or ablation of the fistula is possible and the treatment of choice for nonmalignant fistula. When curative therapy is not possible, this approach also provides the patient minimal morbidity, while resumption of oral intake and faster recuperation. A series of 29 esophagopericardial fistulas, due to causes other than esophageal carcinoma, was reported in 1985 and concluded that surgical drainage of the effusion should occur first with elective operative closure of the fistula second [6]. A case of malignant esophagopericardial fistula resulting in tamponade treated by pericardial drainage followed by esophageal stent was reported in 1999. The perimyocarditis quickly resolved and the patient tolerated oral intake until his death 6 weeks later [2]. Patients with esophagopericardial fistulae can undergo effective palliation by pericardial drainage and subsequent esophageal stenting. If loculations are suspected based on radiographic or echocardiographic findings, a minimal anteriolateral, non-rib spreading thoracotomy will allow debridement and drainage with minimal pain. Further treatment with esophageal stenting and antibiotics can then help these patients regain oral intake and quality of life.
References 1. Renshaw AA, Nappi D, Sugarbaker DJ, Swanson S. Effusion cytology of esophageal carcinoma. Cancer 1997;81:365–372. 2. Kohl O, Schaffer R, Doppl W. [Purulent pericarditis as an initial manifestation of esophageal carcinoma]. Dtsch Med Wochenschr 1999;124:381–385. 3. Furak J, Olah T, Szendrenyi V, Horvath OP, Balogh A. [Esophago-pericardial fistula caused by recurrent esophageal tumor]. Magy Seb 1999;52:89 –91. 4. Navarro P, Heras M, Miro JM, Mateu M. [Cardiac tamponade as the first manifestation of carcinoma of the esophagus]. Med Clin (Barc) 1992;98:661–662. 5. Abiko M, Ohizumi H, Naruke Y, et al. [A case of lung cancer (small cell carcinoma) occurring esophago-pericardial fistula and purulent pericarditis]. Kyobu Geka 1999;52:969 –971. 6. Konttinen MP, Pitkaranta PP, Heikkinen LO, Talja MT, AlaKulju KV. Esophago-pericardial fistula. A case report and review of the literature. Thorac Cardiovasc Surg 1985;33:341– 343.
CASE REPORTS
Comment