Innovative and Successful Management of a Colonic Interposition Graft Pericardial Fistula
Jacquelyn Brandenburg, DO, Jess D. Schwartz, MD.
University of New Mexico, Albuquerque, NM, USA.
Colonic interposition graft (CIG) pericardial fistula is extremely rare. We report the successful management of this nearly universally fatal complication using a novel operative approach.
A 32-year-old female with a history recalcitrant childhood achalasia, many failed attempts at Heller myotomy, and an esophagectomy with CIG reconstruction at age 20, presented with severe sepsis. CT scan revealed a significant pericardial effusion with associated pneumopericardium. A barium swallow revealed a CIG pericardial fistula. At redo left thoracotomy, the distal portion of the CIG was found to be necrotic and draining into the pericardium. The vascular pedicle was identified and preserved, sparing the proximal aspect of the CIG for future anastomosis by resection of the necrotic distal visceral end and creation of a blind pouch. Cervical tube drainage of the remaining CIG was established and a post-op angiogram confirmed an intact blood supply. Eight months later the patient underwent laparotomy to re-established gastrointestinal continuity by anastomosis of her remaining CIG to her remnant stomach.
Patient recovered and was tolerating oral intake at discharge. She developed strictures at the colonic-gastric anastomosis and was managed with serial dilations and stent placement. The patient was followed for over 5 years without further gastrointestinal tract complications.
Ten previous cases of CIG pericardial fistulas have been reported with only one known survivor. Using an innovative surgical technique, preserving the vascular pedicle of the CIG while resecting a portion of the visceral conduit, this case represents the second long term survivor of this rare complication.
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