Radiologic evaluation of postoperative gastropericardial fistula

Abstract

Laparoscopic Nissen fundoplication is the current standard surgical option for complicated GERD and symptomatic hiatal hernia. Though comparable in safety, short-term efficacy, and patient satisfaction when compared with open operation, laparoscopic Nissen fundoplication has demonstrated shorter hospital stays and recuperative times. Commonly reported complications include gastric or esophageal injury, splenic injury, pneumothorax, bleeding, pneumonia, fever, wound infections, and dysphagia. We present an unusual case of gastropericardial fistula that developed as a late complication of laparoscopic Nissen fundoplication performed 4 years earlier.

Figure 1

Chest X-ray obtained at outside hospital shows pneumopericardium (white arrows). Heart size is normal. No pneumothorax is present.

Figure 2

Water-soluble swallow study shows a small outpouching from the fundus of the stomach projecting over the area of the pericardium (white arrow), which is suspicious for gastric fundal ulcer perforation into the pericardial sac and forming a gastropericardial fistula. This persistent finding is seen on multiple images and different patient positions during the study.

Figure 3

CT of the chest immediately after water-soluble swallow study (coronal view). The collection of contrast (white arrow) corresponds with the small gastric outpouching seen in prior upper GI images. This is suspicious for gastric fundal ulcer perforation into the pericardial sac and formation of a gastropericardial fistula.

Figure 4

CT of the chest immediately after water-soluble swallow study showing postoperative changes of Nissen fundoplication. Oral contrast is noted in the distal esophagus/stomach. There is a focal outpouching of contrast and air extending from the superior aspect of the gastric fundus that extends through the left hemidiaphragm and abuts the surface of the posteroinferior pericardium (white arrow). Findings are of large pneumopericardium (white arrowheads) with indications of a gastropericardial fistula, as described above.

Figure 5

Focal collection of contrast (white arrow) in the dependent portion of the pericardial sac. The patient is in the prone position. This is consistent with contrast entry into the pericardial sac from prior recent upper GI studies, confirming the presence of a gastropericardial fistula.

Figure 6

Visualization of gastropericardial fistula in fundus of stomach via endoscope.