Colopericardial fistula following colonic interposition can primary repair be safely performed

1. Ann Case Rep, an open access journal
ISSN: 2574-7754
1 Volume 2018; Issue 07
Annals of Case Reports
Case Report
El Masri S, et al. Ann Case Rep: ACRT-188.
Colopericardial Fistula following Colonic Interposition: Can
Primary Repair be Safely Performed?
Samer El Masri1*
, George Khalife2
, Jaafar AL-Shami2
,Youssef Ghoussoub2
, Salam Abou Rafeh2
,Ahmad Dabbagh3
, Raja
Wakim2
1
Department of Surgery, Division of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
2
Department of Surgery, Division of General Surgery, Mount Lebanon Hospital, Beirut, Lebanon
3
Department of Cardiovascular Surgery, Division of Cardiovascular Surgery, Mount Lebanon Hospital, Beirut, Lebanon
*
Corresponding author: Samer Al Masri, M.D. Chief Resident, The American University of Beirut Medical Center, Beirut, PO
Box 11-0236, Lebanon. Tel: +9619711350000; Email: sa206@aub.edu.lb
Citation: El Masri S, Khalife G, AL-Shami J,Abou Rafeh S, Ghoussoub Y, Dabbagh A, Wakim R (2018) Colopericardial Fistula
following Colonic Interposition: Can Primary Repair be Safely Performed?. Ann Case Rep: ACRT-188. DOI: 10.29011/2574-
7754/100088
Received Date: 16 June, 2018; Accepted Date: 20 June, 2018; Published Date: 28 June, 2018
DOI: 10.29011/2574-7754/100088
Abstract
Colopericardial fistula is a rare long-term complication of colonic interposition. Without prompt surgical treatment, this
disease entity is ultimately fatal. We present a case of a 24-year-old male who underwent colonic interposition for long gap
esophageal atresia two decades prior to presentation, successfully treated with division of the fistula tract, primary repair of the
colonic defect and a pericardial window.
Introduction
Esophageal atresia is a rare congenital anomaly of the
esophagus that is commonly associated with tracheopesophageal
fistula. The cornerstone surgical treatment has always been to
attempt to reconstruct the native esophagus, and to reestablish
primary continuity [1]. Nevertheless, in a minority of cases,
reestablishing the patient’s native esophagus is impractical.
Therefore, in these cases, it would be prudent to abandon the native
esophagus and to proceed with a replacement procedure [2].
Colonic interposition was not popularized for the pediatric
population until the mid-1900s by the work of Sandblom [3].
Complications that have been extensively described include but are
notlimitedto,anastomoticleaks,strictures,colonicredundancy,and
reflux colitis [4]. In this report, we describe a very rare, potentially
fatal, complication of colonic interposition, decades after the
index operation, and the successful treatment modality utilized.
Case Presentation
This is a case of a 24-year-old male, who underwent right
colonic interposition for pure long gap esophageal atresia (Type
A) at the age of 1, and had no complaints until one week prior to
presentation, when he started to experience stabbing chest pain,
high grade fever, and progressive productive cough. At the time
of arrival, he was found to be borderline hypotensive, tachycardic
and tachypneic. He had significant wheezing on auscultation and a
chest x-ray confirmed the presence of left lower lobe pneumonia.
The patient was admitted with a diagnosis of community-acquired
pneumonia, and was started on intravenous antibiotics. However,
his condition deteriorated; he required noninvasive positive
pressure ventilatory support to maintain adequate oxygenation. A
computed tomography scan of the chest with IV contrast revealed
the evidence of pneumopericardium, and a colopericardial fistula
was identified. (Figure 1)

2. Citation: El Masri S, Khalife G, Dabbagh A, Wakim R (2018) Colopericardial Fistula following Colonic Interposition: Can Primary Repair be Safely Performed?. Ann
Case Rep: ACRT-188. DOI: 10.29011/2574-7754/100088
2 Volume 2018; Issue 07
Ann Case Rep, an open access journal
ISSN: 2574-7754
Figure 1: Computed tomography scan of the chest with IV contrast
revealing a fistula between the inferior aspect of the pericardium
(immediately supra-diaphragmatic) and the superior-anterior conduit at
level of the distal anastomosis. It measured 17mm in length and 19mm
in diameter (white arrow). Note the significant pericardial effusion and
pneumopericardium (arrowhead) in both Coronal (A) and Axial (B)
views.
At this point, the patient was started on parenteral nutrition,
switched to broader spectrum coverage, and allowed nothing
orally. Cardiac evaluation with a transthoracic echocardiography
revealed pericardial effusion and constrictive pericarditis. His
condition stabilized over the next 24 allowing further diagnostic
evaluation before attempting surgical treatment.
Endoscopic evaluation revealed the fistula tract leading to
the pericardium at the cologastric junction. Examination of the
stomach and duodenum revealed no pathology (Figure 2).
Figure 2: Endoscopic view of the fistula tract at 38cm from the incisors
though which the pericardium can be seen (Arrow) 1cm defect at the
cologastric junction. Notice the hemorrhagic inflamed colonic mucosa
adjacent to the defect.
With the cardiothoracic surgeon on board, the patient
was taken to the operating room, and the decision was made to
proceed with explorative laparotomy through the previous midline
scar given the caudal location of the fistula. The patient was
prepped, nevertheless, for a possible sternotomy. Upon entering
the abdomen, extensive adhesiolysis was undertaken. The right
colonic graft was identified through the hiatus to the posterior
mediastinum anastomosed to the stomach. A transhiatal dissection
was then undertaken cephalad, until the fistula was clearly
identified entering the pericardium at its most caudal aspect. It was
divided and sent to pathology. At this time, copious irrigation of
the pericardium with warm saline was performed, retrieving dense
and numerous undigested food particles. This process was repeated
several times until the aspirate was completely clear. The colonic
defect was debrided to healthy edges and using interrupted 3-0
Vicryl suture (Ethicon), a primary repair was performed ensuring a
patent lumen. The pericardial defect was enlarged, and a pericardial
window was constructed for drainage. A vascularized segment of
omentum was interposed in-between the colonic graft and the
pericardium. Then, we instructed the anesthesiologist to perform a
methylene blue test through the nasogastric tube, which confirmed
an intact repair. At the end of the procedure, a feeding jejunostomy
tube was constructed to establish postoperative enteral nutrition.
The abdominal cavity was irrigated with warm saline.
Postoperatively, the patient was transferred to the intensive
care unit, maintained on board spectrum antibiotics pending
intraoperative cultures. His course was complicated with a large
left sided pleural effusion that required drainage percutaneously.
His condition improved over the next couple of days. He was
transferred to the hospital ward being already started on enteral
tube feeds. Parenteral nutrition was gradually tapered off. A water-
soluble oral contrast study was performed on postoperative day 12
that revealed an intact repair. The patient was started then on oral
clear liquid feeds, and was discharged home two days later on an
oral feeding plan supplemented with jejunostomy tube feed, and a
course of antibiotics tailored as per the sensitivity of his cultures.
Discussion
The colon was once a popular conduit for esophageal
replacement. The right, transverse or left colon with its vascular
pedicle, in an isoperistaltic or antiperistaltic fashion, could be
utilized. However, the choice of conduit remains to be based on the
surgeon preference and expertise, as previous studies comparing
the outcomes between patients undergoing gastric pullup or
colonic interposition, for benign or malignant etiologies, failed to
show any consistent benefit of one technique over the other [4,5].
Colopericardial fistula and its deleterious sequela of
septic pericarditis is a life-threatening complication of colonic
interposition that has been described previously in a few reports.
The etiology for this complication has been attributed to acid or bile
reflux, and rarely complications of diverticulitis or malignancy in
the interposition graft [6-8]. Our patient had no symptoms of peptic
ulcer disease or bile reflux, and endoscopic evaluation and biopsies
revealed no evidence of any pathology in the residual stomach and

3. Citation: El Masri S, Khalife G, Dabbagh A, Wakim R (2018) Colopericardial Fistula following Colonic Interposition: Can Primary Repair be Safely Performed?. Ann
Case Rep: ACRT-188. DOI: 10.29011/2574-7754/100088
3 Volume 2018; Issue 07
Ann Case Rep, an open access journal
ISSN: 2574-7754
duodenum. However, significant erythema and inflammation were
noted at the cologastric junction (Figure 2).
Thecolonisanorgan,althoughpreviouslythoughtotherwise,
susceptible to acid reflux, with peptic ulcerations developing
at the cologastric junction in around 30% of these patients [8].
Regardless of the etiology, without prompt and aggressive
medical and surgical therapy to control the septic focus (septic
pericarditis) and nutritional support, it is unlikely patients would
survive this fatal complication. We describe a case of primary
repair of the colonic defect, division of the fistula tract through
a midline laparatomy, and adequate drainage of the pericardium
through a pericardial window with a vascularized interposition
Omental graft, obviating the need for a thoracotomy. The patient
did excellent postoperatively, and at 3months of follow up even
gained 5 kilograms of weight from oral nutrition. We believe, as
previous reports have shown [6] that if sufficient healthy tissue
remains after division of the fistula, attempting primary repair in
the aim of avoiding extensive and unnecessary surgical procedures
and preserving the original conduit is prudent.
Conflict of Interest
There are no acknowledgements and we have nothing to disclose.
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