A BRIEF HIATUS: PARAESOPHAGEAL HERNIA REPAIR COMPLICATED BY THORACIC HERNIA SAC

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Paraesophageal herniation (PH) is the displacement of abdominal viscera, particularly the stomach, through the diaphragm into the thorax. Surgical fundoplication can infrequently lead to post-operative complications. We present a unique case of stage IV PH complicated by post-fundoplication insufflated hernia sac causing hemodynamic instability. CASE PRESENTATION: A 77-years-old woman with hypertension presented with dysuria and abdominal discomfort and was found to have hypokalemia, atrial fibrillation (AF), and pyuria. A stage IV PH was noted on computed tomography (CT). She underwent laparoscopic Nissen fundoplication for hernia repair. Postoperatively, she had worsening chest pain, dyspnea and tachycardia. CT scan revealed a large hernia sac with air-fluid level within the thorax causing cardiac shift and compression. The patient was intubated for worsening dyspnea and started on pressors for refractory hypotension. A pigtail catheter was placed under radiographic guidance into the displaced hernia sac with decompression of air and retrieval of fluid with rapid improvement in hemodynamics and cardiac shift. Fluid analysis showed low cell counts and negative cytology with yeast in culture. As tube feeds were introduced, the formulation drained through the hernia sac catheter with an elevated fluid amylase level of 895 raising concern for an esophageal leak. The patient was extubated to high-flow nasal cannula but intermittent hypotension, dyspnea, and overall failure to thrive prompted her family to pursue hospice care. DISCUSSION: PH can cause herniation of abdominal contents into the thorax causing significant morbidity with median age of presentation between 65-75 years (1). With large phrenoesophageal membrane defects, organs including stomach, spleen, and small intestine can herniate. Diagnosis is made by barium swallow, endoscopy or CT (2). Treatment for advanced, symptomatic disease refractory to medical treatment is surgical. Given the need to insufflate the peritoneal cavity, laparoscopic repair can occasionally lead to insignificant surgical emphysema and pneumomediastinum or small pneumothorax (3). However, this can infrequently cause hemodynamic instability, and to our knowledge, there is no literature reporting an inflated visceral peritoneal sac protruding into the thorax causing tension physiology as in our patient. Diagnosis is based on clinical findings of shock and imaging showing mediastinal structure compression and shift. Treatment is based on decompression and, in patients stable for surgery, resection of the hernia sac. CONCLUSIONS: Visceral peritoneal sac herniation and insufflation with air-fluid level causing tension physiology is a rare phenomenon post-PE repair that can cause significant hemodynamic instability and morbidity. Clinical exam and radiographic imaging followed by quick decompression play a key role in swift recognition and urgent treatment. REFERENCE #1: Lebenthal A, Waterford SD, Fisichella PM. Treatment and controversies in paraesophageal hernia repair. Front Surg. 2015;2:13. REFERENCE #2: Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349(oct23 1):g6154-g6154. REFERENCE #3: Singhal T, Balakrishnan S, Hussain A, Grandy-Smith S, Paix A, El-Hasani S. Management of complications after laparoscopic Nissen's fundoplication: a surgeon's perspective. Ann Surg Innov Res. 2009;3:1. DISCLOSURES: No relevant relationships by Pavan Bhat, source=Web Response no disclosure on file for Robert Cole; No relevant relationships by Theodore Plush, source=Web Response