Gastropericardial Fistula after Laparoscopic Surgery for Reflux Disease

Abstract

APAROSCOPIC approaches are now commonly used to treat gastroesophageal reflux disease. 1,2 Many studies have demonstrated the safety, efficacy, and durability of these minimal-access procedures. 3 However, the learning curve for performing laparoscopic surgery in patients with reflux disease is steep, 4 and intraoperative complications can be life-threatening. 3 Reviews of long-term complications have shown that failed repairs (a "slipped wrap" or paraesophageal or hiatal hernia) can cause substantial morbidity. 3,5 We report a case in which a lifethreatening, gastropericardial fistula was a late complication of a laparoscopic Nissen procedure. CASE REPORTA 70-year-old man who was visiting Boston came to the emergency room in January 1998 with pain in his left shoulder that radiated to his neck. The hematocrit was 16 percent. His medical history included symptomatic gastroesophageal reflux that was refractory to medical therapy and prostate cancer, which had been treated with local radiation therapy two years earlier.In December 1996, the patient had undergone a laparoscopic Nissen fundoplication, with resolution of his reflux symptoms. The surgery was performed with a five-trocar technique. The stomach was easily reduced into the abdomen from the hiatal hernia. The short gastric arteries were divided. The right and left diaphragmatic crura were not closed behind the wrap. A complete fundal wrap of the intraabdominal esophagus was performed around an intraluminal bougie. Two nonabsorbable, nonpledgeted sutures secured the posterior portion of the wrap, the esophagus, and the anterior portion of the wrap. The wrap was not secured to the undersurface of the diaphragm.Several months after the surgery, atrial fibrillation and congestive heart failure developed. The atrial fibrillation converted to sinus rhythm with medical therapy. On Thanksgiving Day, 1997, the patient had sudden, severe abdominal pain, which abated after a drenching sweat. Although he did not have additional episodes of severe pain, he had chronic postprandial pain. He lost 9 kg in weight, had intermittent fevers, with temperatures as high as 39.4°C, and had nocturnal sweats.

Pericardial Tamponade: A Life Threatening Complication of Laparoscopic Gastro-oesophageal Surgery

“…Once identified, monitoring for progressive fluid accumulation and tamponade is essential. Potential mechanisms for the development of a pericardial effusion following gastrooesophageal surgery include: direct pericardial trauma, spread of infection from implanted prosthetic material and "sympathetic" pericarditis with effusion [5][6][7]. Sympathetic pericarditis may result from reactive pericardial inflammation in response to foreign material in close proximity to the pericardium and from pericardial trauma related to the surgical procedure.…”

“…Complications secondary to infection or direct trauma such as pericardiotomy-like syndrome [5] and gastro-pericardial fistula [6] have been reported. Bui et al postulated "sympathetic" pericardial effusion secondary to an infected LAGB system in 2003 [7].…”

Gastropericardial Fistula as a Delayed Complication of a Nissen Fundoplication

“…Hamid and coauthors identifi ed 95 cases (mean age, 54 years; range, 1-82) using a Medline search; their review demonstrated that the fi stulas originated from the stomach (46%), esophagus (38%), colon (11%), jejunum (2%), and duodenum (1%) (1). Fiftyfi ve cases developed after surgery, including esophagectomy (24 patients), fundoplication (14 patients, 6 postlaparoscopic), colonic interposition (8 patients), and diaphragmatic hernia repair Th e mortality rate is as high as 50% (5).…”

“…This possibility is much more likely in patients with prior gastroesophageal surgery, including laparoscopic Nissen fundoplication. F istula formation between the gastrointestinal tract and the pericardium is very uncommon and usually occurs after esophagogastric surgical procedures (1)(2)(3)(4)(5)(6)(7)(8). Laparoscopic Nissen fundoplication is the most common surgical treatment for gastroesophageal refl ux disease.…”

Pneumo-pyopericardium Mimicking an Acute Myocardial Infarction. A Rare Complication of an Incarcerated Hiatus Hernia and Gastro-pericardial Fistula

“…7,8 The definite diagnosis of a gastro-pericardial fistula is achieved by performing several noninvasive imaging procedures, including chest X-rays that will show an enlarged mediastinum with fluid and air levels in the pericardial cavity.…”