Esophagogastric fistula: a rare complication of laparoscopic Nissen fundoplication

A 39-year-old Caucasian male, who had suffered since the age of 19 years from gastroesophageal reflux disease and had undergone laparoscopic Nissen fundoplication with initial resolution of his complaints four years earlier, presented with worsening of heartburn and a new onset of dysphagia. Endoscopy detected an ulcerated fistula orifice on the z-line. Retrograde vision revealed intact Nissen fundoplication and the distal orifice of the aforementioned fistula in the funduscorpus transition area (Fig. 1). Biopsies from the ulcer were negative and the patient was treated with long-term highdose proton pump inhibitors. Two months later on followup endoscopy a clean small proximal fistula orifice in the esophagus and a distal one in the stomach (Fig. 2) were detected. Esophagogastric fistula or “double lumen esophagus” is a rare complication of both open and laparoscopic Nissen fundoplication. Regarding laparoscopic anti-reflux surgery we present the fifth case of this unusual complication [1-3]. Overall, pathogenetic causes include prolonged untreated reflux disease with ulcerations and erosions, migration of the wrap, intraoperative injuries, ischemic necrosis, tissue reaction with used sutures or Teflon pledgets, and local existing malignancy or prior surgery [2]. When symptomatic, esophagogastric fistula can be treated conservatively with anti-secretory agents or endoscopically with clip application (either through or over the scope); for non-responding cases laparoscopic gastroplasty or even open surgery could be an option [3]. Esophagogastric fistula: a rare complication of laparoscopic Nissen fundoplication