Cardiac Tamponade After Nissen Fundoplication. Case Report

Introduction Nissen fundoplication is a common and standard surgical procedure for the treatment of gastroesophageal reflux disease and hiatal hernias. [1] However, it is associated with rare but potentially life-threatening complication – cardiac tamponade. [2] Case Presentation A 61-year-old woman presented to the hospital with heartburn, regurgitation and a feeling of fullness after eating over 6 months. Her medical history revealed that she underwent surgery for a diaphragmatic hiatal hernia 8 years ago. Fibrogastroduodenoscopy and gastric radiography confirmed a recurrent grade IV hiatal hernia. A Nissen fundoplication was performed according to plan: the hernia sac was removed, the diaphragmatic crura was sutured using the Nissen technique, and a 10×15 cm "Ultrapro" mesh was placed around the esophagus and secured with 10 staples. 53 hours after surgery, the patient lost consciousness and was transferred to intensive care unit (ICU). Tachycardic atrial fibrillation with heart rates of up to 115 bpm and hypotension occurred, black stools and general weakness were also observed. Echocardiography revealed pericardial effusion with signs of tamponade. Pericardial drainage was performed and approximately 300 ml of blood and clots were removed. Hemodynamics stabilized and sinus rhythm was restored. Sharp staple ends were identified within the pericardial cavity, causing bleeding from the diaphragmatic surface of the right ventricle. Four staples were removed and the bleeding myocardial defects were sutured. The patient showed clinical improvement, was transferred to the abdominal surgery ward and was discharged home one week later. Discussion Cardiac complications are rare but severe after fundoplication. It often results from direct injury to the cardiac tissue during the procedure by the helical tacker, staples or sutures. [3] Cardiac tamponade is one of the most serious complications and can develop up to the 14th day after surgery, so must be considered, especially if the patient becomes hemodynamically unstable. [4] Conclusions This case report brings attention to the precise surgical technique during Nissen fundoplication as well as the need for rapid diagnosis and intervention to prevent rare but lethal complication of cardiac tamponade.