A46-41 Post-HIPEC Colo-Pleural Fistula

Introduction Colo-pleural fistula is a rare condition, typically arising from malignancy, surgery, or trauma, and is characterized by direct communication between the colonand pleural space, resulting in empyema. Fistula formation after hyperthermic intraperitoneal chemotherapy (HIPEC) is exceedingly rare, with most reported cases involving intra-abdominal or enterocutaneous tracts rather than thoracic extension [1]. Case Presentation A 66-year-old male with a history of metastatic appendiceal adenocarcinoma status post HIPEC presented to our hospital with fever, weakness, and pleuritic left-sided chest pain. On arrival, he was hypoxemic, requiring 8 liters of supplemental oxygen with a fever of 38.8 °C. CT chest revealed a large loculated left hydropneumothorax. He was initiated on broad-spectrum IV antibiotics with anaerobic coverage. A left-sided chest tube was placed and drained 1,200 mL of malodorous, feculent-looking fluid. This raised concerns of a fistulous tract with the GI tract. A follow-up CT chest imaging with contrast demonstrated communication between the colon and the pleural cavity consistent with a colo-pleural fistula [Fig. 1]. Pleural fluid analysis was consistent with empyema, and cultures grew enteric organisms. Surgical oncology and thoracic surgery were consulted. He initially underwent a diverting loop ileostomy, followed by left-sided video-assisted thoracoscopic surgery with washout and decortication. Following the interventions, the patient’s clinical status improved, his fevers resolved, and he was gradually weaned off supplemental oxygen. Discussion Colo-pleural fistula is a rare complication following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). The pathogenesis is multifactorial, often involving extensive peritonectomy, diaphragmatic injury or resection, and postoperative infection, which collectively increase the risk of fistula formation [2]. Severe pulmonary complications, including empyema and fistula formation, occur in up to 17% of patients and are linked to decreased overall survival [3]. Diagnosis of colo-pleural fistula requires a high index of suspicion, especially in patients presenting with unexplained empyema and enteric organisms in pleural fluid. Management is multidisciplinary, involving broad-spectrum antibiotics, pleural drainage, and surgical intervention to divert fecal flow and repair the fistula. References 1. Surgical Outcomes of Hyperthermic Intraperitoneal Chemotherapy: Analysis of the American College of Surgeons National Surgical Quality Improvement Program. Jafari MD, Halabi WJ, Stamos MJ, et al. JAMA Surgery. 2014;149(2):170-5. doi:10.1001/jamasurg.2013.3640. 2. Rare Diaphragmatic Complications Following Cytoreductive Surgery and HIPEC: Report of Two Cases.Lampl B, Leebmann H, Mayr M, Piso P. Surgery Today. 2014;44(2):383-6. doi:10.1007/s00595-012-0445-9. 3. Severe Pulmonary Complications After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Are Common and Contribute to Decreased Overall Survival. Sand O, Andersson M, Arakelian E, et al. PloS One. 2021;16(12):e0261852. doi:10.1371/journal.pone.0261852. This abstract is funded by: None