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.
An 84-year-old woman suffered from a type IV diaphragmatic hernia with a tortuous intrathoracic stomach and grade II esophagitis. The stomach was reduced into the abdominal cavity and the hernia sac resected. A coated polyester mesh was attached to the crura with 5-mm titanium helical tacks. After an uneventful recovery, the patient suddenly developed cardiogenic shock on postoperative day 14. A left thoracotomy was subsequently performed. There was active bleeding of the epicardium from a number of pointed lesions, just opposite the tackers which had penetrated the pericardium. The offending tacks were removed and the defects in the epicardium sutured. The patient was discharged 18 days after thoracotomy.