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.
A 42-year-old woman was referred to our center with severe gastroesophageal reflux disease (GERD) 5 years after having an open Nissen's procedure without mesh augmentation elsewhere. She had a giant recurrent hernia and pH-meter proven reflux; manometry showed moderate dysmotility. Surgery took 3 hours because of adhesions, and a configuration 2 graft deployment was performed. Recovery was uneventful until the 6th postoperative hour when orthostatic hypotension (systolic 85–90 mmHg) with an increased heart rate (120–125/min), unresponsive to fluid challenge, became evident. There was no chest pain, her enzyme levels and electrocardiography were normal. As hypotension in resting supine position and shortness of breath became evident, a bedside echocardiography and tomography were performed. Both revealed CT, and tomography also identified several “tacks” as the cause (). She was immediately transferred to cardiac intensive care for a possible intervention to release the tamponade. Heart rate and blood pressure slowly improved with titrated hydration under monitoring. She was followed up by serial echocardiograms, which showed slight decrease in tamponade. On the 4th day, she was transferred to the ward with a 90-minute heart rate and 115–120 mmHg systolic blood pressure. She was discharged from the hospital on the 10th postoperative day. A year after surgery, she was in perfect health, without any need for antiacid medications. Control imaging a month and a year after surgery confirmed the absence of any fluid collection.\nThe hyperdense nature of the element titanium in tomographic imaging allowed the anatomical analysis in this report. Contrast tomography was reconstructed in 3D with special intent to show the spatial distribution of all 16 titanium tacks, which were circumferentially deployed all around the hiatal opening (; Supplementary Data are available online at ). The video of the operation was reviewed, and starting from the first fixation, all tacks were numbered consecutively (). also shows the application of surgical numbering to the corresponding tacks in the 3D image. The axial, sagittal, and coronal sections were re-evaluated in-depth, with the guidance of the 3D restoration (). Targeted marking of any particular tack, by simultaneously identifying the same tack in all sections, allowed us to number all the tacks appearing in any particular tomography slice, according to the surgical numbering. A radiology expert, blinded to the numbering, was asked to assess the tomography slices to verify the positioning of the 16 tacks as probable causes of cardiac injury (coauthor B.A.). The closest distance from each tack to the pericardium was measured (). Tacks without any measurable distance from the pericardium were evaluated as “offensive” as the probable cause of tamponade, whereas tacks with a clear measurable distance were regarded as “nonoffensive” by the radiologist. The number of all tacks were then uncovered.\nFurthermore, tack distribution with special reference to their proximity to the aorta and vena cava was measured.