Commentary: PID

Abstract

Central MessageAggressive definitive surgical management of a rare and usually fatal complication (pyopericardium) of esophageal cancer proved to be the correct decision, with long-term survival of the patient.See Article page e143. Aggressive definitive surgical management of a rare and usually fatal complication (pyopericardium) of esophageal cancer proved to be the correct decision, with long-term survival of the patient. See Article page e143. Acronyms are common in medicine. PID is usually referred to as pelvic inflammatory disease, related to infection of a woman's reproduction system secondary to sexually transmitted diseases. Medical slang for PID is “pus in dere,” which is an appropriate description for this case. Kesler and colleagues1Vardas P.N. Acton M.D. Rosati C.M. Kesler K.A. One-stage surgical management of an esophagopericardial fistula presenting with tamponade.J Thorac Cardiovasc Surg. 2019; 158: e143-e145Abstract Full Text Full Text PDF Scopus (2) Google Scholar encountered a pyopericardium (PID)-related to an esophagopericardial fistula, an extremely rare complication of esophageal cancer. A pericardial effusion is a common finding in the clinical practice of patients with aerodigestive malignancies. It can be an incidental finding, manifestation of metastatic disease, or a complication of treatment. The spectrum of these pericardial effusions ranges from mild asymptomatic effusion to cardiac tamponade with cardiopulmonary instability, as in this report. Management is guided by the hemodynamic impact, size, associated comorbidities, the etiology, and status of the patient's malignancy.2Renshaw A.A. Nappi D. Sugarbaker D.J. Swanson S. Effusion cytology of esophageal carcinoma.Cancer. 1997; 81: 365-372Crossref PubMed Scopus (14) Google Scholar Usually when a patient presents with cardiac tamponade with the history of esophageal cancer, it is local invasion into the pericardial space with development of a malignant pericardial effusion, which is usually a terminal event. To find a pyopericardium related to a esophagopericardial fistula is an extremely rare complication related to esophageal cancer.3Kohl O. Schaffer R. Doppl W. Purulent pericarditis as an initial manifestation of esophageal carcinoma [in German].Dtsch Med Wochenschr. 1999; 124: 381-385Crossref PubMed Scopus (16) Google Scholar, 4Furak J. Olah T. Szendrenyi V. Horvath O.P. Balogh A. Esophago-pericardial fistula caused by recurrent esophageal tumor [in Hungarian].Magy Seb. 1999; 52: 89-91PubMed Google Scholar, 5Navarro P. Heras M. Miro J.M. Mateu M. Cardiac tamponade as the first manifestation of carcinoma of the esophagus [in Spanish].Med Clin (Barc). 1992; 98: 661-662PubMed Google Scholar Historically, treatment would have been drainage of the pericardial effusion only for palliation or with exclusion of the esophagus, thus achieving gastrointestinal discontinuity or esophageal stent placement for esophageal fistula closure.5Navarro P. Heras M. Miro J.M. Mateu M. Cardiac tamponade as the first manifestation of carcinoma of the esophagus [in Spanish].Med Clin (Barc). 1992; 98: 661-662PubMed Google Scholar The authors elected to perform a single-stage surgical intervention, after a hemodynamic stabilizing pericardiocentesis, which included definitive repair (esophagopericardial fistula), resection of the cancer (negative margins), and restoration of gastrointestinal continuity (gastric conduit). Kesler chose a modified McKeown procedure, medical slang a 3-holer, with the conduit in the substernal position. This approach allowed for the definitive treatment of the complication as well as of the underlying cancer. Also, a myocutaneous flap was used for anastomotic reinforcement.6Kesler K.A. Ramchandani N.K. Jalal S.I. Stokes S.M. Mankins M.R. Ceppa D.P. et al.Outcomes of a novel intrathoracic esophagogastric anastomotic technique.J Thorac Cardiovasc Surg. 2018; 156: 1739-1745Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The patient had an uneventful recovery and is currently a long-term survivor of a usually fatal complication and cancer. During training to become a thoracic surgeon, there were 3 rules of survival as a resident, which was to sleep when you can, to eat when you can, and to respect the esophagus. Kesler and colleagues should be congratulated on their no-fear approach to treat life-threatening conditions of the esophagus. Truly, Dr Kesler is a master surgeon who used his vast experience and wisdom of open surgical interventions to definitively treat (3-holer) this usually fatal complication (PID) of esophageal cancer. Even with the use of acronyms and medical slang to describe medical conditions and treatments, the key to success for the surgical treatment of esophageal disease is attention to detail, of which Kesler and his colleagues have set the standard. One-stage surgical management of an esophagopericardial fistula presenting with tamponadeThe Journal of Thoracic and Cardiovascular SurgeryVol. 158Issue 4PreviewEsophageal fistulas to the airway are rare and frequently fatal complications of chemoradiation therapy in the treatment of squamous cell cancers involving the middle to upper thoracic esophagus. We report a very rare case of a 35-year-old man who presented in cardiogenic shock as a result of tamponade secondary to an esophagopericardial fistula after chemoradiation therapy for a squamous cell carcinoma originating in the distal esophagus. Initial treatment included emergency pericardiocentesis. Full-Text PDF Open Archive