Minimal invasive management of rare complication after laparoscopic type IV paraesophageal hernia repair and Nissen’s fundoplication (Part I)

Pornthep Prathanvanich, MD, FRCST, FACS, Bipan Chand, MD, FACS, FASMBS, FASGE. Loyola University Medical Center

Background

Paraesophageal hernias (PHH) constitute approximately 5% of all hiatal hernias. Surgical management of a symptomatic PHH requires reduction of the stomach, closure of the hiatus and fundoplication. Gastric ischemia is a rare complication and difficult to manage. Prevention is the key, however a strategy must be in place if this devastating injury occurs.

This video highlights the finding of gastric ischemia, intraoperative decision-making and subsequent management.

Method

An 80-year-old male was transferred to our tertiary center ten days after having undergone an uneventful laparoscopic repair of a large type IV PHH with fundoplication. In our emergency department, he had signs and symptoms concerning for abdominal sepsis with tachycardia and leukocytosis. Imaging included chest and abdominal computed tomography (CT) and an esophagram (UGI). CT confirmed mediastinal fluid and a few adjacent air bubbles (close to the fundoplication). He did not receive oral contrast with that study. UGI was performed and did show contrast extravasation above the fundoplication at the distal esophagus. Surgical intervention was emergently planned after institution of resuscitative measures and intravenous antibiotic.

Diagnostic laparoscopy revealed full thickness ischemic of the gastric cardia and fundus. There appeared to have been complete ligation of not only the short gastric vessels (as part of the fundoplication) but also ligation of the left gastric arcade. Management required proximal gastrectomy, esophageal decompression, feeding access and mediastinal drainage. The distal esophagus was resected and a handsewn-interrupted closure performed.

Result

The operative time was 110 minutes without perioperative complications. Long-term esophageal decompression was obtained via a novel technique. Percutaneous Transesophageal Esophagostomy tube (PTET) was on the postoperative day 4th after intensive care stabilization. Nutrition was maintained through the previously placed gastrostomy tube in the antrum. Gastrografin swallow at one month demonstrated extravasation of contrast at the transection line with fistulaization into the gastric remnant, with minimal uptake into the drain. Diagnostic upper endoscopy showed erosion of the surgical drain into the lumen of the esophagus. The drain was carefully pulled back under endoscopic visualization. Closure of the perforation was performed with an over-the-scope clip. This management strategy, with esophageal decompression (PTET), gastrostomy tube for nutrition and wide mediastinal drainage has now allowed for definitive therapy. This is planned for at 6 months post insult.

Conclusion

Gastric ischemia after PHH repair with fundoplication is a rare complication often with significant morbidity and mortality. Management requires a thorough understanding of its etiology and surgical options.

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