Barranco Moreno, Antonio

Cadet Dussort, Jean Marie

Casado Maestre, María Dolores

Gómez Rejano, María Eugenia

Morales Conde, Salvador

Méndez García, Cristina

Padillo Ruiz, Francisco Javier

Socas Macías, María

Revista Espanola de Enfermedades Digestivas

María Dolores Casado-Maestre

María Socas-Macías

Salvador Morales-Conde

Cristina Méndez-García

Antonio Barranco-Moreno

Jean Marie Cadet-Dussort

Javier Padillo-Ruiz

María Eugenia Gómez-Rejano

Crossref

Revista Española de Enfermedades Digestivas

Fundoplication intrathoracic migration associated with gastric organoaxial volvulus

idUS. Depósito de Investigación Universidad de Sevilla

CASE REPORTA 49-year-old man presented at the emergency departmentfor severe epigastric pain and a 48-hour episode of vomitingwith a greatly affected general state. This is a patient diag-nosed with  Behçet’s disease and ankylosing spondylitis, oper-ated for a hiatal hernia two months before his admission,where a laparoscopic Nissen fundoplication and pillars closurewere performed. During the immediate postoperative period,he manifested a picture of vomiting and dysphagia after wak-ing up from the anesthetic procedure. Both disappeared withcorticosteroid administration.At the admission to the hospital, the patient showed clearsigns of difficulty breathing, paleness, sweating, tachypnea,and tachycardia. On examination, we found no breath soundsin the right hemithorax, and the abdominal exploration revealedsigns of rigidity of abdominal wall. Chest X-ray (Fig. 1).Our differential diagnosis stated hiatal hernia recurrencevs. secondary acute esophageal perforation for abdominaloverpressure due to persistent nausea (Boerhaave syndrome).A thoraco-abdominal CT scan was requested (Fig. 2).An urgent surgery was performed, where we found a complete transhiatal migration from stomach to chest and an associatedorganoaxial volvulus, as well as a partially disrupted fundoplication. Once the herniated viscera were reintroduced in theabdominal cavity, a proper vascularisation was showed. The fundoplication was rebuilt and the pillars were approached. Anabdominal drainage was inserted and removed 4 days after the postoperative period. DISCUSSIONThe Nissen fundoplication is considered as the “gold standard” procedure in patients which are affected by a gastroe-sophageal reflux disease resistant to conservative management. Thanks to it, efficient clinical and histological results witha low operative morbidity and mortality rates are achieved (1).Long-term antireflux surgery re-operations are close to 3%, as published in the broadest series shown in the bibliography.Fundoplication intrathoracic migration which determines a persistent clinical outcome is the most frequent cause (27.9%)of re-operation in the late postoperative antireflux surgery. In descending order of frequency are described: disruption ofthe fundoplication (22.7%), telescoping (14.1%), paraesophageal hernia (6.1%), disruption of hiatus (5.3%), tight fundo-plication (5.3%) and stenosis (1.9%) (2,3).The need for urgent reoperation (excluding those cases of bleeding during the immediate postoperative period or injuryto nearby organs) is anecdotal.Fundoplication intrathoracic migration associated with gastricorganoaxial volvulus María Dolores Casado-Maestre1, María Socas-Macías2, Salvador Morales-Conde2, Cristina Méndez-García2, Antonio Barranco-Moreno2, Jean Marie Cadet-Dussort2, Javier Padillo-Ruiz2and María Eugenia Gómez-Rejano31Unit of Clinical Management and Digestive Surgery. Hospital Universitario Puerta del Mar. Cádiz, Spain. 2Unit ofInnovation and Minimally Surgery. Hospitales Universitarios Virgen del Rocío. Sevilla, Spain. 3Translation andInterpreting Studies. Universidad Pablo Olavide. Sevilla, Spain1130-0108/2012/104/10/546-547REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVASCopyright © 2012 ARÁN EDICIONES, S. L.REV ESP ENFERM DIG (Madrid)Vol. 104. N.° 10, pp. 546-547, 2012PICTURES IN DIGESTIVE PATHOLOGYFig. 1. It reveals the presence of a right hydropneumothorax with com-pressive atelectasis of the lung and contralateral mediastinal shift.Vol. 104. N.° 10, 2012       FUNDOPLICATION INTRATHORACIC MIGRATION ASSOCIATED WITH GASTRIC ORGANOAXIAL VOLVULUS                        547REV ESP ENFERM DIG 2012; 104 (10): 546-547The differential diagnosis of this report, with cardinal symptoms of dyspnea, epigastric pain, tachypnea and tachycardiacoming after a persistent vomiting episode, and associated to the figure of the chest X-ray (Fig. 1) may correspond to eitherBoerhaave syndrome as a problem related to the fundoplication previously performed. The patient did not show subcutaneousemphysema or pneumomediastinum, which are characteristic findings of transmural distal esophageal perforation. Finally,the CT scan revealed the presence of gastric herniation in the chest cavity.In order to clarify the diagnosis, the upper gastrointestinal investigation can prove the leak and the anomalous positionof abdominal viscera, but it does not provide information concerning the vascular supply, ischemic findings or the existenceof collections. However, the computed tomography (CT) does provide crucial information, so that the need for interventionand the choice of approach can be determined (3).With a view to avoiding this problem, we emphasize the importance of preventing nausea and vomiting in the immediatepostoperative period of hiatal hernia repair, since it may condition the disruption of the fundoplication as well as the closingof the pillars in a way that they could cause hernia recurrence and the development of other complications.REFERENCES1. Parrilla P, Martínez de Haro L, Ortiz A, Molina J. Enfermedad por reflujo gastroesoágico. En: Guía Clínica de la Asociación Española de Cirujanos. CirugíaEsofagogástrica; Madrid: Arán Ediciones; 2005. p. 203-25. 2. Hamdy E. Long term outcomes of laparoscopic antireflux surgery. Hepatogastroenterology 2011;58:56-63.3. Furnée EJ, Draaisma WA, Broeders IA, Gooszen HG. Surgical reintervention after failed antireflux surgery: a systematic review of the literature. J Gas-trointestinal Surg 2009;13:1539-49.Fig. 2. Thoraco-abdominal CT scan. A. Cross-section. B. Coronal  plane. Moderate dilation of the esophagus, visualizing the gastric camera in the right hemithoraxwith herniated stomach through a huge defect in the esophageal hiatus, which is almost 6 cm in diameter. The stomach is over-distended and has a large air-fluid level without showing wall thickening. The position of the stomach in the right hemithorax is the standard one in the cranio-caudal plane (possibleorganoaxial volvulus). Significant mass effect on the structures of the right hemithorax with contralateral mediastinal shift, compressive atelectasis of right lungand partial collapse of the superior vena cava.A B

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Fundoplication intrathoracic migration associated with gastric organoaxial volvulus

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idUS. Depósito de Investigación Universidad de Sevilla