O-086 * LIFE-THREATENING COMPLICATION OF COLON INTERPOSITION AFTER OESOPHAGECTOMY

Abstract

Objectives: Fistula between intrathoracic conduit replacing an oesophagus and adjacent organs is a rare and challenging situation with high mortality rate. Case description: We present a 47-year old woman with congenital oesophageal atresia. During childhood she underwent several operations, eventually with colon replacement of her oesophagus. Subsequently, she developed dysphagia and severe reflux that required two redo thoracotomies and a laparotomy to revise her colo-gastric anastomosis and shorten a redundant colon conduit, with PEG insertion for nutritional supplementation. She presented with progressive weight loss, uncontrolled chest pain and massive upper gastrointestinal (GI) bleeding. A fistula was found between the left ventricle (LV) and the colonic conduit. She underwent urgent sternotomy, repair of LV pseudoaneurysm and colon-LV fistula using cardiopulmonary bypass and closure of defect in the colon by autologous pericardial patch. Pre and intraoperatively she required massive blood transfusions. In early postoperative period she developed leak from the intrathoracic colon to the pericardial space with associated pericarditis and mediastinitis. She required redo left thoracotomy, major decortication, debridement and attempted primary repair of complex defect in the colonic conduit with intercostal muscle buttressing. Few days later she developed sepsis and underwent re-do sternotomy and wide debridement. She remained with an open sternum. After achieving infection control and negative fluid balance re re-do thoracotomy and resection of the intrathoracic colon, proximal stomach and distal oesophagus was carried out, together with diverting cervical oesophagostomy. Subsequently she underwent delayed sternal closure. She had long recovery, but was eventually discharged with improvement of her nutritional status and no evidence of infection. One year after discharge she is alive and well, awaiting final reconstruction with a gastric conduit. Conclusions: Her case illustrates that prompt diagnosis and aggressive staged surgical treatment of LV to intrathoracic colon fistula may prevent an otherwise fatal outcome of this unusual problem.