This case study revolves around an adult patient treated for Gastroesophageal Reflux Disease (GERD) and a Grade 3 hiatal hernia. The individual was referred to a general surgeon for imaging and diagnostic endoscopy. The surgeon recommended a Transoral Incisionless Fundoplication (TIF) procedure, allegedly without adequately explaining the risks, benefits, or alternative treatments such as Nissen Fundoplication. The patient underwent TIF later that month.
Post-operative day zero (POD#0), the patient experienced severe pain, particularly in their shoulder, which was managed with narcotics. Due to the lack of beds on the regular floors, they were placed on the juvenile floor.
On POD#1, the patient’s condition worsened with high pain levels, low Hemoglobin/Hematocrit (H/H), elevated Respiratory Rate (RR), and White Blood Cell count (WBC) of 19.6.
A swallow study with water-soluble contrast was conducted but not with barium, and only an Anteroposterior (AP) view was taken instead of lateral or oblique views. A CT scan revealed moderate pneumomediastinum, significant air near the gastroesophageal junction (GEJ), and a small amount of intra-abdominal free air consistent with post-op findings. Despite increasing WBC counts and persistent tachycardia over the next two days, the patient was discharged on POD#3.
Following discharge, the patient’s condition deteriorated rapidly. They experienced difficulty breathing, rapid weight gain due to water retention, severe back spasms, and intense pain. Upon readmission to the emergency department (ED), they were airlifted to a facility equipped with a surgical ICU. The patient was intubated and underwent surgery to address an esophageal perforation caused by one of the fasteners used during the TIF procedure.
Post-operative complications included severe sepsis and Acute Respiratory Distress Syndrome (ARDS). Although the patient survived, they now suffer from neurological issues secondary to Hypoxic Ischemic Encephalopathy (HIE).
Questions to the expert and their responses
As an expert general surgeon with nearly two decades of experience and over 500 non-bariatric foregut surgeries, what is your experience with hiatal hernias?
I have performed numerous surgeries for hiatal hernias throughout my career.
When performing a TIF, care is taken to avoid perforating the esophagus. However, it is a known risk associated with this procedure. What can be done to mitigate the risk?
In 2020, there were established standards regarding Grade 3 Hiatal Hernias (HHs), including protocols for informed consent that necessitate offering alternatives. I would need to review this case in detail to provide a more comprehensive answer.
What is the discharge standard post-TIF?
The decision to discharge a patient after a TIF depends on several factors, including their post-operative condition. Discharging a patient with tachycardia as described seems unusual.
About the expert
This expert is a seasoned general surgeon with two decades of experience and board certification in surgery. They have held prestigious positions such as an instructor at a renowned medical school, associate chief, and associate professor at a prominent university's School of Medicine. Currently, they serve as the Chief of General Surgery and a professor at a university in the Midwest, demonstrating their ongoing commitment to surgical education and leadership within the field.
About the author