Gastropericardial fistula reported after laparoscopic Nissen procedure

NEW YORK (Reuters Health) – Gastric ulceration is rare but can occur following open Nissen fundoplication. A new case report indicates that the complication can also occur following laparoscopic fundoplication and can actually lead to a gastropericardial fistula.

In the January 31st issue of The New England Journal of Medicine, Dr. Michael T. Jaklitsch, from Brigham and Women's Hospital in Boston, and colleagues report on a 70-year old man who underwent a laparoscopic Nissen procedure in 1996 and returned to the hospital in 1998 with left shoulder pain radiating to his neck. The patient also had history of prostate cancer, which had been treated with local radiation 2 years earlier.

On physical examination, the patient was noted to have supraclavicular adenopathy and an enlarged prostate gland. Blood cultures revealed that the patient was septic and he was started on several antibiotics. After the patient was stabilized, CT and gastroscopy were performed and revealed the presence of a gastropericardial fistula.

The patient underwent fistula repair and made an uneventful recovery. However, biopsy of the left supraclavicular lymph node revealed the presence of adenocarcinoma cells. The patient died 19 months later of metastatic prostate cancer.

The investigators believe that not closing the diaphragmatic hiatus during the original procedure may have allowed the stomach to herniate, ultimately resulting in fistula formation. While not a component of the original laparoscopic Nissen technique, closure of this hiatus is now considered standard practice.

Gastric ulceration occurs in about 3% to 5% of open Nissen procedures, the investigators note. There is no reason to believe the rates would be any lower with the laparoscopic procedure, they add.

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