P1.051. Gastric Conduit–Pericardial Fistula Caused by Gastric Conduit Ulcer After Esophagectomy: Successful Salvage With Thoracoscopic Pericardial Window

Abstract

Abstract Topic Benign Disease: Other Case Submission A 70-year-old man presented with pericardial effusion and suspected gastric conduit–pericardial fistula secondary to gastric conduit ulceration after esophagectomy. He was diagnosed with lower thoracic esophageal cancer in 2021 and underwent neoadjuvant docetaxel/cisplatin/5-fluorouracil therapy, followed by robot-assisted esophagectomy with retrosternal gastric conduit reconstruction. He received 12 courses of adjuvant nivolumab therapy. In January 2024, he continuously used nonsteroidal anti-inflammatory drugs (NSAIDs) for right shoulder pain. He subsequently developed chest discomfort and general fatigue and visited a local clinic, where he was managed by observation. One week later, at a scheduled follow-up visit to our hospital, laboratory testing demonstrated elevated inflammatory markers and electrocardiography showed ST-segment elevation. Transthoracic echocardiography and contrast-enhanced computed tomography revealed pericardial fluid accumulation and an ulcer on the posterior wall of the gastric conduit. Based on these findings, a gastric conduit–pericardial fistula related to gastric conduit ulceration was diagnosed. Pericardial drainage was performed on the day of admission, and intravenous antibiotic therapy was initiated thereafter. Upper gastrointestinal endoscopy revealed ulcers on both the anterior and posterior walls of the gastric conduit; no clear malignant features were observed endoscopically. After drainage and medical therapy, the systemic inflammatory response improved; however, follow-up assessment suggested the persistence of an abscess cavity within the pericardial space despite ongoing drainage. Given the residual intrapericardial abscess cavity after drainage and antibiotic treatment, surgical drainage was selected. On hospital day 25, thoracoscopic pericardial window creation (pericardial fenestration) and feeding jejunostomy were performed under general anesthesia. Postoperatively, the inflammatory markers decreased further, and the clinical status stabilized. The gastric conduit ulcers showed scarring changes during follow-up, and oral intake was resumed after treatment. The pericardial drain was removed on day 52 of hospitalization, and the patient was transferred to another facility for convalescence. This case raises discussion points regarding diagnostic confirmation and step-up management of late-onset suspected microfistulas without an obvious perforation site. In particular, the case was characterized by (i) ST-segment elevation with inflammatory markers prompting cardiac evaluation, (ii) imaging findings of pericardial effusion and posterior gastric conduit ulcer in close proximity to the pericardium, (iii) absence of apparent malignant features on endoscopy, and (iv) persistence of a pericardial abscess cavity after initial pericardial drainage and antibiotics, which was ultimately managed with thoracoscopic pericardial fenestration and enteral access. The questions for the panel discussion included the following: (1) recommended diagnostic workflow to confirm a gastric conduit–pericardial fistula or microfistula in similar settings, including the role and timing of CT, echocardiography, endoscopy, and/or contrast studies; (2) criteria for escalation from pericardial drainage plus antibiotics to thoracoscopic pericardial window creation; (3) indications, feasibility, and risks of endoscopic interventions for gastric conduit ulcers when a pericardial complication is suspected; and (4) preventive strategies after esophagectomy, including long-term acid suppression and analgesic selection in patients requiring NSAIDs.