Teaching Case

A 60-year-old woman with no clinical history of interest underwent scheduled surgery of hiatus hernia, without complications. During the hospital admission subsequent to surgery, the patient began to suffer from vomiting, nausea and chest pain.

Plain chest radiography showed a retro-cardiac gas-filled structure with defined edges (Fig. 1). Upper gastrointestinal series demonstrated a filiform pass of barium along the distal oesophagus at the level of the structure, with slight dilatation of the proximal portion (Fig. 2). A slow contrast filling of the retro-cardiac structure could be observed along the study, as well as delayed passing of the contrast to the infra-diaphragmatic remaining stomach. No images suggesting leakage were found.

Computed tomography images with oral and intravenous contrast confirmed the presence of the retro-cardiac structure completely surrounding the distal oesophagus, apparently in continuity with the gastric fundus. It showed an air-fluid level inside it, with high density similar to oral contrast. The rest of the gastric chamber was located infra-diaphragmatic (Fig. 3 and 4).

Nissen fundoplication is one of the surgical options for treatment of gastroesophageal reflux disease (GERD). The aim of the procedure is to increase pressure at the distal oesophagus in order to avoid reflux. This is achieved by encircling the stomach fundus around the distal oesophagus, covering it 360 degrees [1]. Previous studies describe a high rate of good results (90%). The persistence of symptoms is a good indicator of Nissen procedure failure.

Radiologic studies are useful when failure of the antireflux technique is suspected. Upper gastrointestinal series with oral contrast can show postoperative anatomy and permeability [2, 3]. CT can depict more detailed anatomy and demonstrate the presence of post-surgical complications. Normal imaging appearance is a narrowed distal oesophagus passing through a regular filling defect (the gastric fundus envelope). Besides, the wrap should be located below the diaphragm.

There are different possibilities of failure according to wrap functionality or location [2, 3]. A too tight wrap could show a long (>2-3 cm) and narrow filling defect (distal oesophagus) or a stop with retrograde dilatation. Conversely, if the wrap is too loose or broken, fundus filling defect can be partially or totally absent, with reappearance of gastroesophagic reflux and/or hernia.

The gastric cavity can slide above the diaphragm through a normal positioned and functional wrap. In that case upper gastrointestinal series are not always altered, but there could be a hernia-like image (with an unaltered sub-diaphragmatic wrap) or a sub-diaphragmatic pouch. Perforation would show a leakage of the oral contrast.

Finally, as in our case, the antireflux system can move from its normal position to a supra-diaphragmatic location. Thus, it would show a normal morphology of the fundoplication but in the mediastinum, with a possible constriction secondary to its passage through the diaphragmatic hiatus.

Those are the main possibilities to consider when Nissen procedure failure is suspected.