Esophageal replacement with gastric conduit is a common surgical methodof radical esophagectomy. In these patients, anastomotic leakage or conduit ischemia often develop in the early postoperative period, while diaphragmatic hernias, anastomotic stricture, conduit ulceration, and dysfunctional conduitare frequently seen as the late complications. Among these, the gastric conduit ulceration could progress to a life-threatening gastropericardial fistula and diaphragmatic hernias clearly require urgent surgical care.
Gastropericardial fistula is a rare and severe complication of radical esophagectomy with mortality rate greater than 50%. Clinical presentation of gastropericardial fistula is often non-specific and includes dyspnea, chest pain and sudden death. Our patient complained of left chest pain, nausea and vomiting, which were also the clinical manifestations of diaphragmatic hernias. Therefore, the gastropericardial fistula could be missed for diagnosis while it coexists with diaphragmatic hernia especially at the emergency setting.
Imaging and endoscopy can be used to make the diagnosis of gastropericardial fistula. CT imaging often shows the cardiac enlargement, air or air fluid level in the pericardial cavity, while radiography wtih water soluble contrast can make the fistula tract visualized. Also, gastroscopy can accurately reveal the ulceration or fistula tract. In this case, the gastroscopy could have provided a greater assistance to the diagnosis although it was obviously very difficult to have it at the emergency setting.
Surgical treatment is usually considered as an effective way to quickly improve the prognosis of gastropericardial fistula. In this case, we had resected a part of pericardium and repaired the gastric wall and the patient recovered rapidly.
In conclusion, diaphragmatic hernias and thoracic gastropericardial fistula could be presented simultaneously at patients with a relative long history of radical esophagectomy. CT in combination with radiography with water-soluble contrast can make their diagnosis readily.