Critical Care: Student/Resident Case Report Poster - Critical Care IV |

Fundoplications and Fistulas: A Complex Case of Tracheoesophageal Fistula After a Nissen FREE TO VIEW

Tristan Petrie, MD
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SUNY Upstate Medical University, Syracuse, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):438A. doi:10.1016/j.chest.2016.08.451
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Our case is an interesting, complex and very unfortunate case of a 46 year-old female that suffered a long complicated course of fistula, stenting and respiratory failure 20 years after a Nissen Fundoplication was completed for gastroesophageal reflux disease and hiatal hernia.

CASE PRESENTATION: JA is a 46 year-old female with the above noted past medical history who initially presented to Thoracic Surgery service for management of a esophagogastric fistula found when patient sought evaluation for dysphagia and recurrence of her acid reflux symptoms about 20 years after a Nissen Fundoplication. This initial fistula was attributed to a pledgeted suture and that was removed via EGD. Unfortunately, removing the pledgeted suture resulted in a larger fistula that ultimately required stenting and finally Ivor-Lewis esophagectomy. Unfortunately, the patient suffered an anastomotic leak that required repeat stenting of her gastric sleeve/remaining portion of her esophagus. A plan was formulated with the patient to eventually remove her esophageal stents as she had ongoing dysphagia and difficulties with maintaining adequate nutrition/oral intake. During the course of an EGD to remove the stent a large tracheoesophageal fistula was found 4 cm proximally to the carina and the stent had migrated into the trachea resulting in airway obstruction with thick secretions. The patient had already been intubated for the procedure and using a bronchoscope the tube was advanced proximally 1 cm distal from the carina. The patient was paralyzed and placed in the ICU however she ultimately died from these complications after a family meeting was completed and care withdrawn.

DISCUSSION: Although Nissen Fundoplication is often used in the management of gastroesophageal reflux disease refractory of medical management with excellent long term success rates, invasive esophageal surgeries can still carry a long term risk and complication potential. The long term post-surgical anatomic changes associated with Nissen Fundoplication can eventually lead to multiple types of fistulas including gastrobronchial, gastropericardial, tracheoesophageal and esophagogastric fistulas. These complex fistulas represent significant challenges to Surgical and Medical ICU management including airway management/intubation with bronchoscopy and addition of paralytics that require multidisciplinary critical care.

CONCLUSIONS: Our case is the first on review of literature to highlight 2 distinct types of fistula, both esophagogastric and tracheoesophageal after a Nissen Fundoplication and resultant complications 20 years later.

Reference #1: Tafen et. al. 2016. Esophagogastric Fistula Complicating a Nissen Fundoplication. Journal of Pediatric Surgery Case Reports. S2213-5766(16)30012-4. doi: 10.1016/j.epsc.2016.03.011.

DISCLOSURE: The following authors have nothing to disclose: Tristan Petrie

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