Endoscopic management of rare complication caused by Nissen fundoplication.
Gastroesophageal reflux disease (GERD) affects approximately 10%-20% of adults in Western countries, with cardinal symptoms of heartburn and regurgitation. The most common pharmacological therapy is acid-suppression with proton pump inhibitors (PPIs). Partial responders to PPI treatment are commonly referred for Nissen fundoplication, even though evidence for the effectiveness of the procedure in these patients has yielded mixed results. Surgical management is accompanied by complications including gastric or esophageal injury, splenic injury, pneumothorax, bleeding and others. We present a rare complication of Nissen fundoplication requiring repeated endoscopic and surgical management. A 68-year-old female with past medical history of GERD worsened by hiatal hernia and refractory to PPIs presented with nausea and vomiting for one week. She underwent laparascopic surgical repair of paraesophageal hernia and Nissen Fundoplication a month prior, requiring placement of sutures incorporating the esophagus. Post-procedurally, the patient complained of progressively worsening dysphagia to solids and liquids. On physical examination, the patient was afebrile, tachycardic, tachypneic, and hypertensive. Pertinent labs results included hemoglobin=12.7 g/dL, white blood cells = 6.9 bil/L, platelets = 302 bil/L and creatinine = 0.81 mg.dL. Barium esophagogram showed a patent GE junction with limited passage of contrast through the Nissen site and residual contrast in the distal esophagus despite repeated esophageal contraction. Esophagogastroduodenoscopy (EGD) was performed and revealed an esophageal stricture that was subsequently dilated with a Savary dilator with moderate resistance at 33 and 36 Fr. After dilation, a light blue wire eroded into the mucosa at the gastroesophageal (GE junction). Four days later a repeat EGD revealed multiple sutures in lower esophagus and an ulcerated stenosis at the surgical suture site. Patient underwent laparoscopic dissection of the lower esophagus with prolonged hospital stay and difficult recovery. Operative management of GERD compared to medical management has not shown clear cut benefits. Due to the risk of complications, physicians should be aware of the indications of a Nissen fundoplication and should reconsider using medical management instead. As shown in this case, a potential future for managing such complication can include endoscopic management.
Gjeorgievski M, Cappell MS. Endoscopic management of rare complication caused by Nissen fundoplication. American College of Gastroenterology Annual Meeting, Orlando, FL, October 13- 18, 2017.