P074: PNEUMOPERICARDIUM IN THE SETTING OF TRACHEO-GASTRIC FISTULA
Juliana Morales, MD1; Arnaldo Vera, MD2; 1Jackson Memorial Hospital; 2Miami VA
Background: Esophagectomy and reconstruction with the gastric pedicle is an accepted surgical management for esophageal cancer1. Common complications of esophagectomy are anastamotic leak, pneumothorax, pleural effusion, and respiratory failure2, 1. Formation of gastropericardial fistula, an abnormal connection between the stomach and pericardium, occurs rarely2.
Case Description: A 70-year-old female with a history of adenocarcinoma of the esophagus underwent transhiatal esophagectomy with gastric conduit. The patient initially progressed well, but her postoperative course was complicated by atrial fibrillation, sepsis requiring vasopressors, acute kidney injury requiring dialysis, hypoxic respiratory failure requiring reintubation, and severe acute respiratory distress syndrome. Due to worsening hypoxia, the patient was placed in prone positioning. She then developed a respiratory acidosis and hypercarbia (PCO2 of 90) which prompted aggressive increases in the FiO2 to 100% and PEEP of 90.
The patient was noted to have an air leak coming from her mouth despite the cuff of the endotracheal tube being properly inflated and appropriately positioned. Bronchoscopy was performed. A fistula was visualized between the trachea and gastric conduit. The endotracheal tube was advanced passed the fistula, 1 cm above the carina. Chest x-ray was notable for pneumopericardium. Echocardiogram showed no evidence of tamponade. Due to poor chance of meaningful recovery and need for further invasive procedures, care was withdrawn and the patient expired.
Discussion: Presentation of gastropericardial fistula occurs with sepsis, pericarditis, or cardiac tamponade3 and is a rare cause of hemodynamic instability after esophagectomy1. Most common etiology of gastropericardial fistula is surgery3. Peptic ulcers can lead to ulceration and fistulous tract formation into the pericardium after intrathoracic gastric pedicle pull up2. In this case, fistulous tract formation occurred both into the trachea and pericardium, leading to pneumopericardium.
(1) Zick, G., Boehle, A. S., Frerichs, I., Both, M., Scholz, J., & Weiler, N. (2008). Tension pneumopericardium after esophagectomy: an extremely rare complication. Journal of cardiothoracic and vascular anesthesia, 22(2), 267-269.
(2) Kim WJ, Choi EJ, Oh YW, Kim KT, Kim CW. Gastropericardial fistula-induced pyopneumopericardium after esophagectomy with esophagogastrectomy. Ann Thorac Surg. 2011 Jan;91(1):e10-1. doi: 10.1016/j.athoracsur.2010.09.082. PMID: 21172468.
(3) Davidson, J. P., Connelly, T. M., Libove, E., & Tappouni, R. (2016). Gastropericardial fistula: radiologic findings and literature review. Journal of Surgical Research, 203(1), 174-182.