S2978 Intrathoracic Gastric Incarceration Following Laparoscopic Nissen Fundoplication

Abstract

INTRODUCTION: Nissen fundoplication is the most performed surgical treatment for GERD. Given the complex anatomy of the EG junction, structural complications occur in up to 30% of cases following fundoplication. Our case is that of post fundoplication paraesophageal hernia with intrathoracic gastric incarceration. CASE DESCRIPTION/METHODS: A 57yo F with PMHx of GERD and type III paraesophageal hiatal hernia who had undergone laparoscopic surgery with primary diaphragm repair and Nissen fundoplication 7mo prior presented with acute onset of dysphagia and epigastric pain. CT revealed superoposterior migration of the Nissen wrap above the diaphragm and a well-circumscribed pouchlike sac to the left of the Nissen fundoplication containing an air-fluid level, without evidence of perforation. GI was consulted and the patient underwent EGD revealing a tight Nissen wrap that was barely traversable. The gastric mucosa was congested, inflamed, and ulcerated from the GE junction to the gastric body concerning for acute incarceration and necrosis. Surgery was urgently consulted, and the patient underwent emergent exploratory laparoscopy which revealed incarcerated herniation of the previously performed fundoplication into the chest. The fundus and upper body of the stomach were necrotic. Laparoscopic subtotal linear gastrectomy with mediastinal abscess drainage and closure of the diaphragmatic defect was performed followed by intraoperative EGD. The patient was discharged a few days later and is currently doing well. DISCUSSION: Nissen fundoplication is a widely accepted and commonly performed anti reflux surgical procedure. The gastric fundus is wrapped around the intraabdominal esophagus, after mobilizing the esophagus and reducing the hiatal hernia, if present. The rate of serious complications has been documented as less than 5%. Incarceration post fundoplication is usually a late diagnosis as it presents with non-specific symptoms of abdominal pain, nausea, and vomiting. EGD with comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Paraesophageal hernia is one of the complications reported after laparoscopic Nissen fundoplication, and it requires emergency operation when associated with incarceration, obstruction, or strangulation of the stomach. There should be high index of suspicion for complications in patients with history of Nissen fundoplication for early detection, prompt treatment, and satisfactory outcomes.Figure 1Figure 2Figure 3