P186 CAROTID-GASTROPLASTY FISTULA: AN UNCOMMON CAUSE OF HEMATEMESIS IN THE DELAYED POSTOPERATIVE PERIOD AFTER ESOPHAGECTOMY

Abstract

Abstract Aim To describe a case report of a carotid-gastroplasty fistula post esophagectomy with a successful result. Background & Methods Upper gastrointestinal bleeding due to a fistula between esophagus or gastroplasty and carotid vessels is infrequent. It is usually due to malignant tumors, penetrating trauma, foreign bodies or radiotherapy. Results A 55-year-old man, with background of laryngeal squamous cell carcinoma that was treated with total laryngectomy and tracheostomy followed by radiotherapy, and posterior recurrence of squamous cell carcinoma at the upper esophagus required total esophagectomy with pharynguectomy and lymphadenectomy, and reconstruction with gastroplasty with anastomosis to the floor of the mouth and pectoralis muscle flap. During this second postoperative period, patient developed a left hemiplegia secondary to thrombosis of the right common carotid artery. After recovery, the patient had repeated episodes of hematemesis that required hospital admission and blood transfusion. After several episodes with conservative management, upper endoscopy revealed blood oozing close to the anastomosis with no other findings. Once again, the patient returned to the emergency department with massive hematemesis, being visualized by endoscopy a high-flow arterial bleeding close to the anastomosis of the floor of the mouth. Arteriography showed the already known thrombosis of the right common carotid artery and the origin of the bleeding distal to that occlusion, where it was repermeabilized by a branch of the right vertebral artery. Given the inability of selective embolization by interventional radiology, urgent surgical approach was decided, performing a right lateral cervicotomy and identifying a fistula that communicated the common carotid artery with gastroplasty. It proceeded to close the fistulous orifice of the arteria and the gastroplasty with a continuous suture. A partial sternocleidomastoid muscle flap was interposed between the two sutures. The postoperative evolution was satisfactory. Patient was discharged 16 days after surgery and being currently stable without signs of hemorrhagic neither oncological recurrence. Conclusion Carotid-gastroplasty fistula is a rare complication with high mortality rate due to its more frequent presentation: the massive hematemesis. Gastrointestinal endoscopy and angiography allow us to diagnose and treat this complication, however in massive and uncontrollable bleeding, surgical approach is indicated. Prognosis will depend on the early diagnosis and a therapeutic individualization is required.