Cardiac Tamponade as a Life-Threatening Complication of Laparoscopic Antireflux Surgery: The Real Incidence and 3D Anatomy of a Heart Injury by Helical Tacks

Abstract

Background: Cardiac tamponade (CT) is a dreadful complication of laparoscopic antireflux surgery (LARS) with unknown incidence, and preventive measures are yet to be defined. Incidence during LARS with respect to usage/configuration of graft deployment is analyzed. Three-dimensional (3D) analysis of tack distribution provided anatomical insight to prevent cardiac injury.Materials and Methods: Data regarding the usage and configuration of graft deployment are retrieved from the prospective database. Grafting was “posterior” or “posterior + anterior.” Incidence of CT in all hiatoplasties is calculated. Tomography is reconstructed in 3D, showing the spatial distribution of the tacks. Tacks are numbered in the surgical video. Corresponding numbering is applied to the tacks in any particular tomography slice, utilizing the 3D images as an interface. A numbering-blinded radiologist is asked to identify the offending and the nonoffending tacks as the cause of tamponade. Tack-to-pericardium distances are recorded. Tacks having no measurable distance from the pericardium are regarded as offensive.Results: One CT occurred in 1302 consecutive LARS (0.076%). The incidence is 0% when “no” (379) or “posterior” (880) graft is used as opposed to 2.3% rate in “posterior + anterior” (43) grafting. The distribution of “offensive,” “nonoffensive but nearest,” and “safe” tacks followed a pattern. All offensive tacks belonged to the anterior graft fixation, which we referred as the critical zone.Conclusion: CT during LARS is rare, and associated with graft fixation anterior to the hiatal opening. Avoiding graft fixation to the critical zone may prevent cardiac injury.

Iatrogenic cardiac tamponade as a mortal complication of peri-hiatal surgery. Analysis of 30 published cases

“…All ICTs in diaphragmatic [18, 19, 20] and ventral herniorraphies [3, 9, 16, 17] occurred because of graft fixation anterior to the hiatal opening. Regarding anti-reflux/hiatoplasties [2, 5, 7, 9, 11, 13], the injury occurred anterior to the hiatal opening except in one [12]. Among graft fixation-related ICTs, the most common cause of injury was helical tack (n:13, 56.5%).…”

“…Echocardiography (EC) and tomography were efficient in diagnosing ICT. Tomography was also able to identify the cause of injury if hyperdense titanium helical tacks were the fixators [2, 6, 11].…”

“…Over the last two decades, increasing number of reports pointed out iatrogenic cardiac tamponade (ICT) as a mortal complication of graft fixation for the repair of peri-hiatal mechanical defects. Repair of hiatal [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15], ventral [3, 9, 16, 17] and diaphragmatic hernias [18, 19, 20] with mesh-augmentation resulted in ICT and deaths. ICTs during peri-hiatal surgery unrelated to graft fixation were also reported [13, 21, 22, 23, 24, 25, 26].…”

“…The reported mortality is between 37.5-66.6% [9, 12] and the number of incidents seems to increase [2, 3]. This is unacceptable as ICT due to peri-hiatal surgical trauma almost exclusively occurs during the repair of a mechanical defect which is a benign condition.…”

“…As a referral center for the surgical treatment of hiatal hernias [27, 28], after confronting with an ICT following laparoscopic anti-reflux surgery [2] (LARS), we conducted an in-depth analysis of the reported cases in peer-reviewed medical journals. The main aim of this review is to emphasize the importance of awareness for the prevention and better management of this extremely mortal, but avoidable complication.…”