A case of gastropericardial fistula of a gastric tube after esophagectomy: a case report and review

A 65-year-old man who had received an esophagectomy 10 years earlier was admitted to our hospital for right chest pain. Preoperative examinations showed pneumopericardium, a retrosternal gastric tube, and an active gastric tube ulcer. We diagnosed gastropericardial fistula of the gastric tube ulcer. Emergency surgery included lavage and drainage of the pericardial cavity and plombage of the rectus abdominis muscle flap to the posterior space of the gastric tube. Total parental nutrition and/or enteric nutrition were provided. Due to minor leakage from the ulcer, the patient could start oral intake on the postoperative 49th day, and was discharged from the hospital on the postoperative 86th day after physical rehabilitation. He has been free from complications for more than 33 months after surgery. Here, we review the literature and discuss the etiology and treatment of choice for this rare yet lethal complication in the follow-up after esophagectomy.


Background
Recent advances in thoracic surgery and post-surgical management in intensive care units (ICUs) have improved the survival of esophageal cancer patients after esophagectomy; many patients often survive more than five years. However, gastric tubes that replace esophagi may erode, leading to gastric tube cancer or perforated gastric tube ulcer. Complications after gastric tube ulcer depend on the posterior-mediastinal, retrosternal or subcutaneal location of the gastric tube. Perforated ulcers of gastric tubes in the posteriormediastinal or retrosternal spaces, if they penetrate the neighboring trachea, thoracic aorta, or pericardium, are often lethal [1][2][3][4].
We report here a rare rescued case of pericarditis due to gastropericardial fistula of the gastric tube ulcer after esophagectomy, and review 29 cases.

Case presentation
A 65-year-old Japanese man was taken to National Hospital Organization Mito Medical Center by ambulance for severe colic right chest and back pain. He was lucid and body temperature was 36.7°C. His blood pressure was 127/97 mmHg, but atrial fibrillation (af), tachycardia, and ST-segment elevations in V5 and V6 were observed in the electrocardiogram ( Figure 1A). Cardiomegaly was observed in the chest X-ray ( Figure 1B). Severe inflammation was apparent, with a white blood cell (WBC) count of 9,100/μl and C-reactive protein (CRP) of 21.87 mg/dl (Table 1, left). He was hospitalized in the Department of Cardiology and conservatively treated with fluid replacement and anti-biotic chemotherapies (cefazolin). His condition worsened, with WBC and CRP increasing to 12,100/μl and 30.34 mg/dl, respectively, with liver and renal dysfunction (Table 1, right). Oxygen inhalation was required for worsening respiratory dysfunction, and he entered multi organ failure (MOF). Four days after admission, computed tomography (CT) showed pneumopericardium and a neighboring gastric tube that replaced the esophagus after esophagectomy (Figure 2A, B). The patient had a history of esophagectomy followed by reconstruction with a gastric tube via the retrosternal route for esophageal cancer 10 years previously in other hospital. One image in the whole body CT ( Figure 2B) suggested the presence of a gastropericardial fistula protruding from the gastric tube and splitting the metal staples. Upper GI endoscopy confirmed an active open ulcer that penetrated the pericardium within the gastric tube at 40 cm from the incisors ( Figure 2C).
We performed emergency surgery to rescue this patient from sepsis. First, we approached to gastric tube by upper median laparotomy, given the results of CT and upper GI endoscopy. The xiphoid process and lower tip of the sternum were removed, and many adhesions were released via the right side of the minor curvature of the gastric tube to avoid injuring the right gastroepiploic artery (RGEA), which feeds the gastric tube pedicle and should be on the left side of the pedicle. We finally identified the gastropericardial fistula. A perforated ulcer of the gastric tube was detected near the bare metal staples that lined the minor curvature in the lower gastric tube, which were initially covered by seromuscular sutures as elsewhere on the gastric tube. The pericardium was opened only by releasing adhesions between the pericardium and gastric tube due to gastropericardial fistula. The pericardial abscess was saline-lavaged and a pericardial drainage tube was placed. A muscle flap was then prepared with the pedicled right rectus abdominis muscle to fill the space between gastric tube and pericardium, and wound was closed. We also drained gastric juice intermittently with a naso-gastric tube (NG tube). Post-operative CT showed the drainage tube in the pericardial space and a plombaged muscular flap between gastric tube and pericardium ( Figure 3).
The pericardial abscess had already led to MOF, acute renal failure, liver dysfunction, as well as respiratory failure. Therefore, we postoperatively treated the patient in the ICU with mechanical ventilation, circulatory maintenance by catecholamines, and continuous hemodiafiltration (CHDF). For increased bilateral pleural effusion, we placed bilateral thoracic drainage tubes on the 4th postoperative day (POD). Blood oxygenation improved and he was released from mechanical ventilation on the 9th POD. On the 18th POD, gastrogram showed minor leakage from the gastric tube to the pericardium, but    the drains were sufficient for pericardial drainage. He was treated with continuous pericardial drainage and nutrition support by enteric diet tube (ED tube) in the jejunum and/or by total parenteral nutrition via central venous catheter, because he sometimes experienced diarrhea with enteral tube feedings. On the 49th POD, leakage disappeared on the gastrogram, and the patient started oral intake by water drinking. On the 76th POD, gastroendoscopy showed a healing (H1) ulcer in the gastric tube (40 cm from the incisors) ( Figure 3B). He was discharged from the hospital on the 86th POD, after physical rehabilitation. He has resumed daily life and is free from complications more than 33 months after surgery.

Review of reported cases
There are only two reports of a gastropericardial fistula of a gastric tube ulcer after esophagectomy [1,5]. The other 26 cases of pericardium-penetrating gastric tube ulcers have been reported in Japan, mostly Japanese conference proceedings or case reports in Japanese. All 29 cases, including the current case, are listed in Table  2; all cases were reconstructed via a retrosternal route, except two via a posterior mediastinum, one via intrathorax, and one unknown case. Postoperative durations vary from 2 months up to 12 years. Initial symptoms are usually chest pain or chest discomfort, with 12 patients (41%) initially presenting at cardiovascular/internal medicine or general practitioners. The current case was presented to and primarily treated by cardiologists. Conservative therapy, percutaneous pericardial drainage, or surgical drainage was adopted for 10 (37%), eight (30%), and nine patients (33%), respectively ( Table 2). Thirteen patients were rescued, three in 10 by conservative therapies, two in six with trans-cutaneous drainage, including one that eventually needed additional surgical treatment, and eight in nine in surgical drainage; rescue ratios of 30%, 33%, and 89%, respectively. Prognosis in surgical drainage is much better than that in conservative therapies or in percutaneous drainage.

Discussion
The stomach is the organ most used for reconstructions after an esophagectomy for esophageal cancer patients; in Japan, a retrosternal route is preferred, where the gastric tube is pulled up [6]. Recent advances in surgical procedures as well as ICU care have improved the postoperative prognosis of esophageal cancer patients, but longer post-surgical periods can lead to problems with gastric tubes, such as bleeding, perforated ulcers, or gastric tube cancers. More than 13% of patients eventually have gastric tube ulcers [7], which can cause massive bleeding, perforation, or penetration through neighboring vital organs [1][2][3][4]. Gastropericardial fistula is highly lethal, with a high mortality of more than 50% (Table  2). Almost all cases were reconstructed via the retrosternal route, as the gastric tube is close to the pericardium. The blood supply for the stomach is mostly dependent on the left gastric artery (LGA), so a gastric tube without the LGA reduces blood supply by 84% at distal sites or by 40% to 52% at middle or proximal sites, where blood supply is replaced by the RGEA [8]. Blood supply also declines more in the retrosternal than the posterior mediastinal route [9]. This decreased blood flow can cause the ulcer, even in the normal healing process [10]. This case showed a thinned, weakened gastric tube wall, with simple closure of a penetrated ulcer usually insufficient. Muscle flap plombage can help treat pericardial or mediastinal abscesses, as we used here with rectus abdominis muscle for a good outcome [11][12][13].

Conclusions
Esophageal cancer patients have prolonged survival after esophagectomy, but gastric tube ulcers can be life-threatening. We found that both surgical drainage and muscle flap plombage can be beneficial for treating ulcers. Gastropericardial fistula of a gastric tube ulcer should be part of the differential diagnosis in patients with an esophagectomy, especially via retrosternal route, that present with chest pain. Similarly, routine examination of the gastric tube by upper GI endoscopy could help avoid this high-mortality comorbidity.

Consent
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.