SESSION TYPE: Surgery Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Colo-pericardial fistulas are exceedingly rare. They have typically occurred after esophageal replacement for other disease processes. Only one previous case has occurred in the setting of anatomically native colon which involved colonic strangulation secondary to a diaphragmatic hernia.
CASE PRESENTATION: A 58 year old man with a history of T4N0M0 cecal cancer, with invasion through the diaphragm to the right lung, presented with chest pain. He was tachycardic, hypotensive, and displayed clinical findings consistent with cardiac tamponade. A pericardiocentesis was performed, resulting in aspiration of air and feculent material. CT scan confirmed the presence of a colo-pericardial fistula. The patient was taken to the OR where a right anterior thoracotomy and laparotomy was performed. His tumor was found to be invading through the diaphragm into the middle lobe of the right lung and was densely adhered to the pericardium. En bloc resection was achieved by removing a portion of the right diaphragm, fifth and sixth ribs, pericardium, and middle lobe of the right lung. When the pericardium was incised, stool was identified in the pericardial space which was irrigated with betadine. In addition, a right hemicolectomy with primary re-anastamosis was performed. The chest and pericardial space were drained widely. The diaphragm was reconstructed with Alloderm mesh and the pericardium was left open. He had an uneventful post operative course and was discharged on post-op day 22.
DISCUSSION: This case represents the first reported colo-pericardial fistula as the result of tumor erosion. Review of the literature shows that this unique clinical entity can present as pericarditits, pneumopericardium, and cardiac tamponade. This patient’s risk for diaphragmatic tumor erosion, and eventual colo-pericardial fistulaization, was exacerbated by aberrant anatomy. Intraoperatively, he was found to have non-rotation of the midgut resulting in a redundant mesentery allowing cecum migration above the liver. This anatomic colonic variant of Chilaiditi Syndrome, placed the cecal tumor in close proximity to the pericardium. Key principles in management included broad spectrum antibiotics, adequate pre-operative resuscitation, and surgical drainage.
CONCLUSIONS: Though now fatal in 50% of reported cases (4/8), colo-pericardial fistulas are a surgically treatable condition that should be considered when patients with colonic tumors present with the cardiac symptoms as described above.
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2) Jouret F, Castanares-Zapatero D, Laterre P (2010) Delayed colopericardial fistula and pyopneumopericardium. Intensive Care Medicine 36:557-558
3) Parmar J, Probert C, Clarke D, Temple J (1989) Colo-pericardial and colo-caval fistula: Late complication of colon interposition. European Journal of Cardio-thoracic Surgery 3:371-372
DISCLOSURE: The following authors have nothing to disclose: Travis Cotton, Benjamin Haithcock, Mark Joseph
No Product/Research Disclosure InformationUNC Hospitals, Chapel Hill, NC