the rapid increase in the number of bariatric surgeries such as sleeve gastrectomy ( sg ) or roux - en - y gastric bypass has driven a parallel increase in revisional bariatric surgeries which is needed in 550% of patients [ 1 , 2 ] . leaks remain a major complication after primary sg , due to its associated high morbidity and mortality [ 3 , 4 ] . according to a recent review comparing primary and revisional sg , management of leaks after sg is challenging and more complex , including surgical revision , percutaneous drainage of abcess , enteral hyper - alimentation and antibiotics therapy [ 69 ] . endoscopic approach developed recently using deployment of stents or pigtail drain [ 8 , 9 ] . however , pigtail drain acts as a foreigner body , which can migrate through fluid collection . we reported the first case of esophagopericardial fistula ( epf ) secondary to migration of a double pigtail drain , set up in order to resolve a gastric leak after revisional sg . a 31-year - old woman , who underwent revisional sleeve gastrectomy ( rsg ) 12 days ago in another hospital , was admitted in our multidisciplinary care team dedicated to the management of bariatric complications , with severe sepsis . emergent chest and abdominal computed tomography ( ct ) scan showed a deep - seated abscess in link with a fistula on the upper third of the staple line . surgical revision was performed to treat peritonitis and included abdominal washout , abdominal drainage close to the staple line and a feeding jejunostomy , respectively . medications included proton pump inhibitors , appropriate antibiotics , somatostatin analogs and exclusively parenteral nutrition followed by enteral nutrition via the feeding jejunostomy . after the initial re - operation , percutaneous drainage ( using 14fr and 10fr external pigtail drains , respectively ) was required on postoperative day ( pod ) 8 due to persistent intra - abdominal abscess on ct scan . during follow - up , a plastic 4 cm x 10 french double pigtail drains was placed on pod 21 through the staple line orifice by endoscopy ( figs 1 and 2 ) . external drainage ( inserted during radiological procedure on pod 8) was removed 3 days later not only because of clinical and biochemical patient 's improvement but also to avoid the development of an external fistula . figure 1:fibroscopy : a 5-mm fistulous hole on the high part of the stomach . control x - ray after the double pigtailed drain has been put up . on pod 13 , the patient experienced retrosternal pain , breathlessness , tachycardia ( 110 beats per minute ) and pyrexia ( 38.5c ) . chest ct scan performed emergently confirming a fistula between the pericardium and the esophagus related to the proximal end of the double pigtail drain ( figs . stabilization was achieved with catecholamines and fluids and the multidisciplinary team decide to operate urgently . therefore , a right - sided thoracotomy was used to enter the pleural cavity through the seventh intercostal space . the intraoperative situs showed a 15-mm defect of anterior side of the esophagus with penetration to the pericardium . a pericardial incision was performed in order to evacuate turbid fluid followed by a pericardial window for continuous drainage . because of severe sepsis , the esophagus was defunctioned with a cervical esophagostomy , a gastrostomy and a previous feeding jejunostomy . an elective reconstruction of his esophagus with the colon will occur 6 months later . figure 3:circumferential pericardial effusion ( arrow ) . 
 figure 4:proximal end of the double pigtail drain externalizes in the pericardium ( arrow ) . figure 5:coronal view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) . 
 figure 6:axial view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) . coronal view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) . axial view of opacification on ct showing the externalization of the drain in the pericardium ( arrow ) .
abstractesophagopericardial fistula ( epf ) is an uncommon but life - threatening complication of upper gastrointestinal tract surgery or endoscopy , which is related to anastomotic breakdown , chronic infection or esophageal traumatism . 
 we first describe the first case of an epf secondary to double pigtail drain migration : an endoscopic internal approach for the treatment of leak following revisional sleeve gastrectomy .