Unwrapping the problems: endoscopic repair of fundoplication fistula
Michael Ma, Arvind J. Trindade, Petros C. Benias
Abstract
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TopicsEsophageal and GI Pathology · Gastrointestinal disorders and treatments · Diverticular Disease and Complications
Fundoplication is the recommended surgical management for gastroesophageal reflux disease 1 . However, common postoperative complications such as dysphagia in up to 46% 2 , and rare complications such as esophagogastric fistula (EGF), can develop. Surgical revision is needed in approximately 11% of those undergoing fundoplication. We present a case of endoscopic management of EGF in the setting of prior fundoplication.
A 38-year-old patient with a history of Nissen fundoplication with subsequent takedown with myotomy and partial fundoplication experienced multiple food impactions requiring 38 endoscopies in the past 4 years. Prior endoscopy was notable for an EGF at the gastroesophageal junction, with the distal orifice in the area of the fundus. This fistula was leading to repeated food impactions that required endoscopic removal. Given the frequency of endoscopic interventions, the patient agreed to pursue endoscopic dissection of the plicated tissue forming the EGF and gastric peroral endoscopic myotomy (G-POEM) to manage gastroparesis.
The shelf of the EGF formed from the plicated tissue was dissected with a hybrid knife ( Video 1 ). The fistula was completely obliterated after complete dissection. G-POEM was also performed successfully and uneventful. An overall improvement in symptoms was noted following the procedure, and reflux disease was controlled on medication.
EGF is a rare complication of fundoplication and can cause a myriad of symptoms depending on the size and location of the fistulous tract. There are case reports on EGF but literature is limited, with refractory disease often necessitating surgical intervention 3 . We present a patient with a large symptomatic EGF causing dysphagia and food impaction. Endoscopic repair of the EGF successfully treated symptoms. As the shelf forming the fistulous tract was created by fundoplication and consisted of gastric tissue, it was safe to dissect and obliterate the fistulous tract.
Endoscopy_UCTN_Code_TTT_1AT_2AC
The reference list from the paper itself. Each links out to its DOI / PubMed record.
- 1Slater BJ Collings A Dirks R Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)Surg Endosc 20233778180610.1007/s 00464-022-09817-336529851 · doi ↗ · pubmed ↗
- 2Lee Y Tahir U Tessier L Long-term outcomes following Dor, Toupet, and Nissen fundoplication: a network meta-analysis of randomized controlled trials Surg Endosc 2023375052506410.1007/s 00464-023-10151-537308760 · doi ↗ · pubmed ↗
- 3Gkolfakis P Katsogridakis J Schizas D Esophagogastric fistula: a rare complication of laparoscopic Nissen fundoplication Ann Gastroenterol 20162954410.20524/aog.2016.007827708524 PMC 5049565 · doi ↗ · pubmed ↗