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A STRUCTURAL SETBACK- ESOPHAGEAL PERFORATION FOLLOWING CONCOMITANT TRANSORAL INCISIONLESS FUNDOPLICATION (CTIF)
Hamza Khan
*1,2, Afsheen Moshtaghi
1,2, Rizwan Jafri
21Internal Medicine, Midwestern University, Glendale, AZ; 2Northern Arizona Healthcare, Flagstaff, AZ
IntroductionConcomitant Transoral Incisionless Fundoplication (cTIF) combines laparoscopic hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) to treat gastroesophageal reflux disease (GERD) in patients with large hiatal hernias (>2 cm). TIF uses the EsophyX device to create a full-thickness valve at the gastroesophageal junction. Studies show that cTIF reduces GERD symptoms, improves quality of life, and decreases proton pump inhibitor (PPI) dependence. While effective, cTIF carries risks, including esophageal perforation, which occurs in 19.8% of cases, according to FDA data. This case report discusses the clinical challenges and management of esophageal perforation after cTIF.
CaseA 47-year-old female with chronic GERD and obesity underwent elective cTIF and robotic hiatal hernia repair. Post-surgery, she was discharged after diet tolerance. Four days later, she presented with shortness of breath, hypoxia, and chest pain. CT imaging revealed pneumomediastinum, bilateral pleural effusions, and extraluminal air, suggesting esophageal perforation. The patient received broad-spectrum antibiotics and underwent emergent robotic exploration and esophagogastroduodenoscopy (EGD). No perforation or leak was found, and mediastinal drains were placed.
Post-surgery, the patient was intubated and monitored in the SICU. After attempting oral intake, blue dye was seen in the right Jackson-Pratt (JP) drain, suggesting a microperforation. A repeat EGD revealed an 8mm mucosal tear, treated with clips. The patient was kept NPO and started on total parenteral nutrition (TPN). Imaging showed resolution of pneumomediastinum, and pigtail catheters were removed. Despite improvement, the patient developed milky fluid from the JP drain, indicating a recurrent fistula. JP drain cultures grew yeast, leading to treatment with anidulafungin. TPN was switched to cyclic administration. The patient stabilized, was advanced to a full liquid diet, and was discharged on TPN with follow-up care.
DiscussionEsophageal perforation is a potential complication of fundoplication procedures. In cTIF, perforations can occur during device insertion or fastener deployment. Proper management includes stopping oral intake, using broad-spectrum antibiotics, and performing surgical or endoscopic repair. Early detection and appropriate intervention are essential to reduce morbidity and mortality after cTIF.
CT Chest with contrast post op day 4 revealing Postoperative fundoplication with extraluminal gas and pneumomediastinum.
Small Fistula in the lower third of the esophagus. This was confirmed by contrast through the fistula under flouroscopy. Extravasation of contrast was not noted after clips were placed.
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