MSS 2021 SPRING ePOSTER
GASTROPERICARDIAL FISTULA FOLLOWING COLLIS GASTROPLASTY AND NISSEN FUNDOPLICATION
Saranya Prathibha MD, Ranjan Gupta MD, Ilitch Diaz-Gutierrez MD, Amit Bhargava MD, Rafael S. Andrade MD, Madhuri V. Rao MD
Presenter: Saranya Prathibha MD; BA University of Minnesota
Introduction/Objective: Fistulas are a known complication of Nissen fundoplications. Here we present a rare case of a gastropericardial fistula following Collis gastroplasty and Nissen fundoplication causing pericardial tamponade.
Case Presentation: A 70 year old female with a past medical history of GERD status post hiatal hernia repair with Collis gastroplasty and Nissen fundoplication several years ago presented to an outside hospital with chills, chest pain and cough. Workup was notable for pericardial gas and effusion prompting treatment of pericarditis. Due to lack of improvement and echocardiogram showing concern for pericardial tamponade, a pericardial window was performed with temporary drain placement. The day following drain removal, she had worsening chest pain and shortness of breath. Imaging showed worsening pericardial effusion so she underwent pericardiocentesis where gastric contents were aspirated. She was then transferred to our hospital for further management. Upon arrival, she was emergently taken to the OR where she became unstable with induction and needed an emergent pericardial window. During endoscopy, bubbling was visible through her pericardial window confirming a connection to the GI tract. Surgical approach was via a left thoracotomy. We performed a transdiaphragmatic takedown of her Nissen fundoplication, exposing a defect just distal to the staple line of her Collis gastroplasty within the wrap. A wedge resection of the stomach was performed and a G tube was placed. Her incisions were closed leaving the pericardial window to close with secondary intention. Post-operatively her hospital course was remarkable for failure to transition her G tube to a GJ tube necessitating an emergent laparotomy with gastric wedge resection, PEG placement and J tube placement. She recovered well after this operation with her pericardial window wound healing nicely. She was subsequently discharged to a long term rehabilitation facility.
Discussion: Gastropericardial fistulas after Nissen fundoplication are a very rare entity with prior research limited to case reports. Mortality of gastropericardial fistulas are reported to be greater than 50%(1). The etiology behind the formation of these are unclear, however ulcers, stitch abscesses and ischemia are included in the differential (1,2,3). In addition, mechanical factors such as angulation of the lesser curve from the wrap should also be considered (4). Reports of gastropericardial fistula after Collis gastroplasty for an intra-abdominal Nissen fundoplication are even more rare. The location of the fistula was just distal to the staple line of the gastroplasty within the wrap, which could suggest irritation from the staples being compressed by the wrap. Literature describes treatment of the fistula with drainage of the pericardium and repair of the stomach with or without omental coverage, similar to our approach(5).
Conclusion: We present a unique case and describe the successful management of a patient with a gastropericardial fistula causing pericardial tamponade after a prior hiatal hernia repair with Nissen fundoplication and Collis gastroplasty.
Resources:
1. Murthy S, Looney J, Jaklitsch MT. Gastropericardial fistula after laparoscopic surgery for reflux disease. N Engl J Med. 2002 Jan 31;346(5):328-32. doi: 10.1056/NEJMoa010259. PMID: 11821509.
2. Agrez MV, Ferguson NW. Aorto-gastric fistula following Nissen fundoplication. Aust N Z J Surg. 1990 Oct;60(10):823-5. doi: 10.1111/j.1445-2197.1990.tb07482.x. PMID: 2403331.
3. Campbell R, Kennedy T, Johnston GW. Gastric ulceration after Nissen fundoplication. Br J Surg. 1983 Jul;70(7):406-7. doi: 10.1002/bjs.1800700705. PMID: 6871620.
4. Scobie BA. High gastric ulcer after Nissen fundoplication. Med J Aust. 1979 May 5;1(9):409-10. doi: 10.5694/j.1326-5377.1979.tb127003.x. PMID: 470776.
5. Sihvo EI, Räsänen JV, Hynninen M, Rantanen TK, Salo JA. Gastropericardial fistula, purulent pericarditis, and cardiac tamponade after laparoscopic Nissen fundoplication. Ann Thorac Surg. 2006 Jan;81(1):356-8. doi: 10.1016/j.athoracsur.2004.08.048. PMID: 16368406.
