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185 LEFT ATRIAL-ESOPHAGEAL FISTULA: INTRAOPERATIVE DIAGNOSIS AND SUCCESSFUL MANAGEMENT C Soulellis, M Nguyen, S Trop, P Szego, L Ferri Departments of Gastroenterology and Thoracic Surgery, McGill University, Montreal, Quebec
INTRODUCTION: Non-traumatic atrial-esophageal fistulas are usually fatal and diagnosed post-mortem. We present the first case of intraoperative diagnosis and successful surgical management of a left atrial-esophageal fistula in a 70-year-old woman with a history of chemotherapy, external beam radiotherapy, and brachytherapy for esophageal cancer who presented with massive upper gastrointestinal bleeding following biopsy of an esophageal lesion.
CASE: A 70-year-old woman was diagnosed with stage IIB carcinoma of the distal esophagus which was managed with a two-month course of chemotherapy, external beam radiotherapy, and brachytherapy. Following this, she developed chronic dysphagia due to multiple radiation-induced esophageal strictures, requiring 2 dilations and percutaneous endoscopic gastrostomy (PEG) feeding tube insertion. Her clinical status remained stable until she presented to the emergency room a year later with a mild upper gastrointestinal bleed. Gastroscopy demonstrated the presence of a lower esophageal ulcerated lesion that was biopsied with ensuing massive hemorrhage. A Blakemore tube was inserted, resulting in stabilization of the patient until a semi-elective Ivor-Lewis esophagectomy was performed. Intraoperatively, the biopsy site was found to be within a membrane overlying a left atrial-esophageal fistula. This was repaired and the patient recovered.
DISCUSSION: Nontraumatic atrial-esophageal fistula is a rare and usually fatal condition. In this case, a diverticulum likely formed from an eroded esophageal wall weakened by radiation and dilations, which then fused with the left atrial wall. Subsequent instrumentation at gastroscopy likely perforated this common wall resulting in a fistula draining into the esophagus. Diagnosis is challenging due to rarity, non-specific classical symptoms, and failure of non-invasive diagnostic tools; surgery remains the most common diagnostic modality. Death in all previous cases has resulted from movement of blood, air, or food across the fistula, with ensuing hemorrhage or neurological deficits. An aggressive surgical approach with closure of the atrial defect is essential to prevent fatal hemorrhage or emboli in good operative candidates.
LEFT ATRIAL-ESOPHAGEAL FISTULA: INTRAOPERATIVE DIAGNOSIS AND SUCCESSFUL MANAGEMENT
C Soulellis, M Nguyen, S Trop, P Szego, L Ferri
Departments of Gastroenterology and Thoracic Surgery, McGill University, Montreal, Quebec