A 61-year-old female with a history of gastroesophageal reflux disease and hiatal hernia developed hemopericardium and tamponade one day after laparoscopic hiatal hernia repair and Toupet fundoplication. The patient underwent emergency pericardiocentesis and subsequent surgical pericardial window. During surgery, a tack that had been used to secure the mesh to the inferior aspect of the diaphragm was found to have penetrated the pericardium near the right ventricle. The patient recovered without further complications.
A 50-year-old female with gastroesophageal reflux disease treated with omeprazole, with an endoscopy results of type I hiatal hernia, suggestive findings of Barrett's esophagus, chronic superficial gastritis and polyps on gastric corpus and fundus, along with a manometry revealing a nonspecific esophageal disorder, underwent an elective laparoscopic Nissen fundoplication with polytetrafluoroethylene mesh repair of the esophageus hiatus with no intraoperative complications. The patient was discharged on the first postoperative day and coursed asymptomatic for three days, reporting only mild epigastric pain and adequate food intake.\nOn the fourth postoperative day, she went to the ER after a witnessed syncopal episode with hypotension of 70/40 mmHg, tachycardia of 147 bpm, tachypnea of 30 bpm, and 35.5ºC of temperature. She was pale, notably, her external jugular veins were distended, with muffled heart sounds, normal abdominal examination showed no alteration on surgical wounds and she had delayed capillary refill; she integrated Beck’s triad, thus, cardiac tamponade was suspected, fluid therapy with lactate ringer’s solution was provided with adequate hemodynamic response, also omeprazole, analgesics, and antibiotics were administered.\nHer laboratory tests were: hemoglobin 11.5 g/dL, hematocrit 33.8%, platelet count of 370,000/HPF, leucocytes 12.8/HPF, neutrophils 8.9/HPF, D-dimer 1094 ug/L, creatinine 0.98 mg/dL, glucose 305 mg/dL. Electrocardiogram (ECG) showed sinus tachycardia and low voltage QRS complexes, the chest X-ray revealed pericardial effusion with a characteristic “water bottle sign” (Figure ), echocardiography reported 400 cc pericardial effusion coupled with right ventricular diastolic dysfunction and a left ventricle intramural hematoma. The CT scan demonstrated a close proximity of the tacks, used on her prior surgery for hiatal mesh fixation, to the inferior surface of the hearth (Figure ), with pleural and pericardial effusion (Figure ).\nOnce initial stabilization was achieved, the patient went to the ICU and underwent a failed attempt of ultrasound guided pericardiocentesis (PC), attributable to the hiatal mesh presence; therefore, the patient went into surgery, where a pericardial window was performed via thoracotomy; 300 cc of hematic pericardial effusion were drained along with approximately 600 cc of pleural effusion, two pleural drains were left in place.\nThe patient’s postoperative course was completely uneventful; an echocardiogram was performed 24 hours after surgery showing no pericardial effusion, thus the drains were removed when a minimal output was achieved on postoperative days 4 and 7, she was discharged asymptomatic 13 days after her intervention.