Successful endoscopic drainage for gastropericardial fistula caused by a gastric conduit ulcer after esophagectomy.

Abstract

Gastric conduit ulcer is a postoperative complication of esophagectomy. However, penetration into the pericardium is extremely rare and often fatal. Although surgical drainage is standard treatment, optimal management when surgery is difficult remains unclear. A 60-year-old man in shock was transferred to our hospital 2 years after mediastinoscopic esophagectomy with gastric conduit reconstruction for esophageal cancer. Computed tomography revealed air and fluid in the pericardial cavity. Upper gastrointestinal endoscopy revealed a perforated gastric conduit ulcer. The patient was diagnosed with mediastinitis and purulent pericarditis. Emergency laparoscopic transhiatal exploration and placement of a chest tube in the left pleural cavity were performed; however, dense adhesions prevented access to the perforation site and pericardial cavity. Because direct pericardial drainage could not be achieved, endoscopic drainage was performed, resulting in rapid improvement of inflammatory findings and a favorable outcome. Few cases of pericardial penetration caused by gastric conduit ulcers have been reported, all showing a rapidly progressive course. Therefore, this condition should be considered an acute, life-threatening event requiring prompt management. Adjunctive endoscopic drainage may serve as a complementary rescue option in selected patients when conventional surgical or percutaneous access to the pericardial cavity is technically difficult or fails to achieve direct drainage.