T HE use ofsegments ofcolon to replace

\oi. 101, No. COLONIC PERICARDIAL FISTULA* By W. B. MILLER, NI.!)., and \V. 11. NIcALISTER, M.D. ST. LOUIS, MISSOURI T HE use ofsegments ofcolon to replace 01#{149} bypass obstru cti ng esophageal lesions was introduced in i 9 1 1 I)v Vulliet in France arii Kelling6 in Germany. In i 921 IdIndblad8 described the earliest successful use of colon for esophageal substitution in children. It has only been since the mid 19505 that intrathoracic colon for esophageal bypass has gained widespread usage in thoracic surgery. I he purpose of the authors is to describe a case of colonic transplant necrosis, wi th resultant mediastillitis, pericardi tis, and colonic pencardial fistula. Progressi ye enlargement of the cardiac silhouette atl a pneumopenicandium were the chief roentgenographic featu res. ILLUSTRATIVE CASE A 2 year old male was noted to have burns of the mouth following lye ingestion. For the next 3 weeks he was able to take only oral fluids. The first admission to St. I ouis Children s Hospital was I month after the lye ingestion, at which time the oral cavity had healed and there were no abnormal physical findings. An esophagogram I day after admission revealed marked chronic ulcerative esophagitis, with narrowing extending from the aortic knob to 2 cm. above the gastroesophageal junction (lig. 1). Lsophagoscopy 2 days later showed posterior esophageal wall granulation tissue 13 cm. from the mouth and circumferential granulations at 16 cm., through which No. 10-14 bougies could be passed. The patient continued oh a liquid diet and was discharged to be re-evaluated in 6-8 weeks for possible esophageal bypass. 1)uring the next month the child experienced progressive dysphagia. l hree days prior to the second admission (2 months post lye ingestion), the patient developed fever and a productive cough. A chest roen tgenogram demonstrated a confluent right lower lobe pneumonia. Under direct laryngoscopy a catheter was passed through the esophlic. I. ESOj)hagOgralll. There are ulcerations of the esophagus with marked narrowing extending from the aortic arch tojust above the cardia. agus into the stomach. One week later esophagoscopy showed a marked stricture 17 cm. from the mouth. Two weeks after esophagoscopy a small abscess cavity appeared in the cehlter of the right lower lol)e infiltrate. The cavity and pneumonia progressively cleared. A right colopyriformostomv and transverse cologastrostomv were performed. The colon segment received its blood supply from the colic branch of the ileocolic, right colic and middle colic arteries. The segment was placed retrosternallv. Intestinal continuity was reestablished by an ileocolostomy. A gastrostomy was performed, and a chest tube inserted into the right pleural space. The postoperative course was characterized b intermittent low grade fever and some difficultv with fluid maintenance. Six days after surgery a chest roentgenogram showed enlargement of the heart shadow. Pericarditis secondary to mediastinitis was postulated (Fig. 2). The patient developed anasarca with marked facial involvement. At the same time dyspnea, rales and hepatomegaly were noted. An electrocardiogram was consistent with myocardial disease or pericarditis. Previous electrocardiograms had been normal. * From The Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri 311

312 W. B. Miller and W. H. McAlister october, 1967 11G. 2. Posteroanterior chest roentgenogram showing increase in cardiac silhouette, and a diffuse pneumonia involving all lobes. Chest roentgenograms 4 days later again demonstrated a large cardiac silhouette. Pneumopenicardium and bilateral pneumonic infiltrates were evident. Perforation of the colon was postulated and a hypaque swallow study performed. Contrast material passed through the colon transplant which had marked mucosal irregularity down to an area just above the diaphragm, where the contrast medium flowed into the pericardial cavity (Fig. 3 and ). Roentgen (Ii agnoses were: colonic pericardial fistula (secondary to necrosis of the colon transplant) and pneumonia. The patient was taken from the Radiology Department directly to the operating room. The entire colon segment from the pyniform sinus to the stomach was observed to be ne- Fic. 3. Anteroposterior chest roentgenogram. Oral hypaque passes from the necrotic interposed retrosternal colon segment into the pericardial cavity. Air is also present in the pericardial cavity. crotic. There were marked mediastinitis and pericarditis. Fluid was present in the peritoneal cavity. I he entire transplanted colon segment was removed and the mediastinum debrided. The opening into the penicardial cavity was enlarged and the penicardium sutured to the antenor chest wall. The patient expired following closure of the incisions. Autopsy revealed an acute and chronic esophagitis with marked stricture formation, bilateral pleural effusions and pneumonia in all lobes, greatest in the right lower lobe, a i cm. abscess cavity in the right lower lobe, and acute, partially organized fibrinous pericarditis. DISCUSSION There has been increased use of the colon for esophageal replacement or bypass in recent years. The indications for transplantation of the colon are: progressive esophageal obstruction, either from m alignancy or benign stricture; certain instances of esophageal atresia (with or without tracheo-esophageal fistula); and esophageal vanices that have failed to respond to vascular shunting procedures. 4 Preference as to the use of either ascending or descending colon is dependent on the individual surgeon, but the anatomic length of the colon available on either side may be the deciding factor. 6 The advantage of the colon is that it has sufficient length along Fic.. Spot roentgenogram showing the colonic pericardial fistula (arrows). The colon is edematous, markedly ulcerated, and contains a tube.

vol. 101, No. Colonic Pericardial FstuIa Ij with ease of mobilization, a diameter great enough that there is little likelihood of anastomotic stricture, an adequate blood supply, and resistance to acid peptic digestion.2 9 The colon segment functions primarily as a passive conduit with gravity flow and may undergo progressive dilatation. #{176} 6 Gross states that the procedure should not be done before i year of age.5 The segment elongates with growth of the child. 2 The intrathoracic colon transplant can be placed in the pleural cavity or in the retrosternal space. It may also be put in the retrocardiac position with retention of the esophageal hiatus.2 Complications include leakage or dehiscence at the esophagocolic or gastrocolic anastomosis. Small leaks at the cervical anastomosis can usually be managed conservatively.7 6 Obstruction may occur at the various anastomoses or as the colon passes through the diaphragm. There may be kinking and obstruction of the redundant intrathoracic colon. Additional reported complications include : superficial wound and intrathoracic infections; recurrent m alignancy ; aspiration pneumonia; pulmonary embolism ; air-way obstruction; pneumo thorax ; recurren t nerve injury; cystic dilatation of esophageal remnant; suggest pericarditis and associated mediastinitis in the absence of acute cardiac failure in colon transplant patients. Dcvelopment of a pneumopericardium suggests a diagnosis of colonic penicardial fistula secondary to colon necrosis. The diagnosis should be confirmed by a contrast study with water soluble iodine containing contrast media. Other causes of pneumopenicardium include recent open heart surgery, trauma, malignant tumors, gasforming organisms, perforation into the pericardium by inflammatory foci from surrounding structures, perforation of a gastric ulcer into the heart directly or by formation of a subphrenic abscess, and dissection through the diaphragm into the penicardium. A primary suppurative pencarditis may perforate into the surrounding lung. 5 Pulmonary cavitation, pneumothorax adjacent to the heart, or mediastinal emphysema may be confused with pneumopenicardium on plain chest roentgenograms.3 Pneumopenicardium can be distinguished by a shift in the air away from the dependent side on decubitus chest roentgenograms. Air in the penicardium does not rise above the aortic knob with the patient upright. The lateral chest roentgenogram can usually differentiate pneumomediastinum in which the air collects principally in the anterior mediastinum and along the great vessels. The thymus may be elevated away from the great vessels with pneumomediastinum in children. gastric atony; regurgitation of material from stomach; excessive oropharyngeal secretions; and diarrhea. Drug reactions, infectious hepatitis, cardiac failure, and myocardial infarction have also occurred. 4 13 14 16 Arterial insufficiency or venous obstruction may lead to bowel necrosis and perforation, poor anastomotic SUMMARY healing, or intravascular thrombosis. When necrosis appears late, the patient may have progressive dysphagia, and the bowel transplant may become a fibrous cord.4 The colonic pencardial flatula necrosis can be localized or involve the. This was mawifested roent- by p ssive#{235}hlargement of entire transplanted colon. In this reported case, necrosis of the colon segment resulted in mediastinitis, pericarditis and eventually a colonic pencardial fistula. The pericardium was not William B. Miller, M.D. The Edward Mallinckrodt knowingly opened during the first surgical Institute of Radiology procedure. 510 South Kingshighway A sudden increase in heart size should St. Louis, Missouri 63110

314 W. B. Miller and W H. McAlister OCTOBER, 1967 The authors are grateful to Dr. D. Torrance for his constructive suggestions in reviewing the manuscript. REFERENCES i. BELSEY, R. Reconstruction of esophagus with left colon. 7. Thoracic & Cardiovasc. Surg., 1965, 49, 33-55. 2. BENTLEY, J. F. R. Primary colonic substitute for atresia of esophagus. Surgery, 1965, 58, 731-736. 3. HEBERER, G. Zum Krankheitsbild des Pneumoperikards. Chirurg, 1950, 2!, 174-177. 4. HONG, P. W., SEEL, D. J., and DIETRICK, R. B. Use of colon in surgical treatment of benign strictures of esophagus. Ann. Surg., 1964, z#{243}o, 202-209. 5. HOPKINS, W. A., and ZWIREN, G. T. Colon replacement of esophagus in children. 7. Thoracic & Cardiovasc. Surg., 1963,46,346-358. 6. KELLING, G. Oesophagoplastik mit Hilfe des Querkolon. Zentralbl. Chir., 1911, 38, 1209-1212. 7. LUNA, R., and ERNST, R. W. Colon interposition for treatment of benign and malignant constricting esophageal lesions. 7.A.M.A., 1963, 184, 114-119. 8. LUNDBLAD, 0. Ueber antethorakale Esophagoplastik. Acta chir. scandinav., 1921, 53, 535-9. MARTIN, L. W., and ILEGE, J. B., JR. Use of colon as substitute for esophagus in children. Am. 7. Surg., 1964, zos, 69-74. 10. MAY, I. A., BYRNE, W. D., YEE, J., HARDY, K. L., and SAMSON, P. C. Left colon total bypass for benign and malignant disease of esophagus. Am. 7. Surg., 1964, zos, 204-214. ii. NARDI, G. L., and GLOTZER, D. J. Anastomotic ulcer of colon following colonic replacement of esophagus. Ann. Surg., 1960, 152, 10-12. 12. NEVILLE, W. E., and CLOWES, G. H. Colon replacement of esophagus in children for congenital and acquired disease. 7. Thoracic & C ardiovasc. Surg., 1960, 40, 507-516. 13. NEvILLE, W. E., and CLowEs, G. H. Reconstruction of esophagus with segments of colon. 7. Thoracic & Cardiovasc. Surg., 1958, 35, 2-22. 14. PELLETT, J. R. Colon interposition for esophageal bypass or replacement. A.M.A. Arch. Surg., 1964, 89,169-179. 15. ROMHILT, D. W., and ALEXANDER, J. W. Pneumopyopericardium secondary to perforation of benign gastric ulcer. 7.A.M.A., 1965, 191, 140-142. i6. WOLFF, W. I. Colonic interposition as esophageal replacement. Am. 7. Surg., 1966, iii, 698-703.

This article has been cited by: 1. U. Imran Hamid, K. Booth, K. McManus. 2012. Is the way to a man's heart through his stomach? Enteropericardial fistula: case series and literature review. Diseases of the Esophagus no-no. [CrossRef]