Pneumopericardium: A Rare Complication of Antireﬂ ux Surgery

Pneumopericardium is a rare clinical entity, occurring in the setting of thoracic trauma, malignancies, or mechanical ventilation. Very few cases report pneumopericardium as a complication of gastrointestinal tract surgery. Signs and symptoms may be frustrating, ranging from asymptomatic to chest pain, sepsis, hemodynamic instability, pericarditis, or even cardiac tamponade. Clinical pathognomonic signs of pneumopericardium include pericardial metallic tinkling friction rub and mill wheel murmur. Diagnostic work-up includes electrocardiogram, chest radiography, and, computed tomography imaging. A gastro pericardial ﬁ stula should be considered a rare diﬀ erential diagnosis for acute chest pain in patients with a history of gastroesophageal surgery. Rapid recognition and treatment avoid life-threatening complications. The successful outcome of gastro pericardial ﬁ stula treatment depends on both emergency and deﬁ nitive surgical management. The survival rate with conservative management is poor. We present the case of a 78-year-old patient suﬀ ering from pneumopericardium and pericardial infusion, due to a ﬁ brotic ﬁ stula between the Nissen’s valve, occurring 10 years after redo antireﬂ ux surgery. Treatment included broad-spectrum antibiotics, and emergency surgery for pericardial drainage, biopsy of the valve’s defect, suture, and omentoplasty.


Case presentation
The approval of the hospital's ethics committee was obtained to present the following case.A 78-year-old female patient was admitted to our hospital with complaints of recurring epigastric pain and diarrhea.The clinical workup revealed collagenous colitis.Upper GI endoscopy was normal.Her medical history included gastroesophageal re lux treated by Nissen fundoplication in 1980 with redo surgery in 2010.While hospitalized, she presented acute retrosternal and epigastric pain not responding to usual medication.Clinical evaluation revealed hemodynamic stability, pericardial metallic tinkling friction rub, mill wheel murmur, and no signs of peritonism.Blood analysis showed a slight in lammation while high-sensitive troponin dosage and leukocytosis were within normal range.Radiologic evaluation by CT scan revealed pneumopericardium associated with a istula path going from the Nissen's fundoplication valve towards the pericardial cavity (Figures 1,2).

Introduction
Pneumopericardium is de ined as the presence of air in the pericardial cavity.Bricheteau irst described this rare entity in 1844 [1][2][3].He discovered a sign in a patient with hydro pneumopericardium that since then has been considered as pathognomonic of this entity, the bruit de moulin (mill wheel murmur), consisting of a luctuating precordial sound, although it usually appears only in cases of complicated pneumopericardium [3].
The etiology of pneumopericardium is classi ied into two main groups: traumatic and non-traumatic.The causes of traumatic pneumopericardium are multiple and varied, with open or closed traumas presenting the highest incidence [3].The most representative non-traumatic pneumopericardium causes include severe asthma, esophageal ulcers, neoplasms, and spontaneous esophageal rupture [3].
Few cases report pneumopericardium as a complication of gastrointestinal tract surgery.
Rapid recognition and treatment of this pathology are essential to avoid serious conditions.We present the case of pneumopericardium occurring 10 years after redo antire lux surgery.
Treatment included pericardial drainage, biopsy of the valve's defect excluding ulcus and neoplasia, gastric suture, and omentoplasty.Post-operative recovery was marked by atrial ibrillation and early dysphagia linked to lower esophagus oedema resolved by the administration of glucocorticoids (Figure 3).

Discussion
Gastropericardial istula is a rare and highly morbid condition associated with high mortality rates of up to 50%, irst described in 1844 by Bricheteau [1,2].
Operative management has contributed to a statistically signi icant reduction in mortality from 69 % in the pre-2000 era to 11% in the post-2000 era [4].
Previous esophagogastric surgery is the most common risk factor accounting for 47% of all reported cases (including transthoracic esophagectomy, Roux-en-Y gastric bypass, and more commonly Nissen fundoplication) [2].Antire lux surgery accounts for 14,7% of reported gastro pericardial istulas [5].
Of the twenty patients, 18 survived and were discharged, two died three weeks after surgery.The last two patient's survival is unknown.
Of the twenty patients, none received conservative treatment.Three of the twenty cases bene ited from initial pericardial drainage, followed by surgery (three days later for one, ten days later for the other two) [17,21].
In the majority of cases (17/20), the surgery consists of excision of the istula, repair of the stomach, and drainage.
In two cases, due to the uncertainty of the success of a primary repair, a Malecote catheter was placed in the gastric perforation, which was closed tightly around the tube using interrupted sutures [15].The catheter was then brought under the diaphragm and out the anterior abdominal wall as a controlled istula similar to a gastrostomy [15].This drain was removed 1 month after surgery [15].
Of the twenty cases, several different approaches were identi ied, the most common being thoracotomy (10/17), two of which were associated with laparotomy.
The pathophysiology of gastro pericardial istula remains unclear [2].Possible pathophysiologic mechanisms include previous gastroesophageal surgery, peptic ulceration usually associated with hiatal hernia, trauma, infection, malignancy, presence of a foreign body both ingested and/or implanted, caustic agent ingestion, or a combination of the above.
In the context of anti-re lux surgery, postoperative scar tissue, gastric fundus abnormal adhesions, and disruption of the normal curvature of the stomach are pathologic conditions offering a pathway for benign ulcers to erode into   the adjacent organ.Indeed, gastric ulcers, a slipped wrap, or a para esophageal/hiatal hernia are the most important risk factors reported [2].
Approximately 3% to 5% of open Nissen fundoplication procedures are complicated by gastric ulcerations and in most cases, the ulceration occurs high on the lesser curvature of the stomach, close to the fundoplication [2].
The clinical presentation of gastro pericardial istula ranges from referred pain in the left shoulder due to diaphragmatic or pericardial irritation, heartburn, epigastric tenderness, dyspnea, vomiting, hematemesis, or melena to sepsis.Chest pain or left shoulder pain was a typical symptom in 66% of the cases [6].Other patients suffered from dyspnea, fever, shock, and even cardiac arrest due to cardiac tamponade [6].In the case of paucisymptomatic patients these symptoms may be present months or years earlier [6].
The diagnostic work-up should include an electrocardiogram showing repolarization disorders such as widespread ST-segment elevation probably due to pericardial irritation.Chest radiography classically shows pneumopericardium, while computed tomography imaging reveals hydro pneumopericardium and the origin of the istula path.Exceptionally, a water-soluble swallow study can be used, or even esophagogastroduodenoscopy, although controversial due to the potential risk of tension pneumopericardium after gastric insuf lation [4].
Clinicians treating patients who have had previous oesophagogastric or diaphragmatic surgery need to be aware that symptoms of atypical chest pain, hemorrhage, GI obstruction, or even shoulder tip pain may be a sign of enteric istula formation and refer urgently to a surgeon familiar with these complications [5].
The successful outcome of gastro pericardial istula treatment depends on both emergency and de initive management [1].Emergency management includes early recognition of pneumopericardium and pericardial decompression [1].De initive management is resection of the istula and repair of diaphragmatic hernia [1].The treatment of gastro pericardial istula includes antibacterial/ antifungal therapy, luid resuscitation, nutritional support, and surgery, even in multi-morbid patients [6].Early surgical intervention to correct the gastro pericardial istula and to drain the pericardium is highly recommended to control infection and prevent cardiac tamponade [6].Survival rate with conservative management is reported to be only 6% [6].However, current advances in diagnosis and early treatment of surgical procedures and perioperative care may radically improve postoperative survival.
In our case, the istula path was observed between the Nissen's valve and the pericardium without signs of the valve's abnormal position (slipping Nissen), and without ulcus formation.Large-spectrum antibiotic therapy combined with laparotomy with istula's path resection, suture of the gastric wall, and transperitoneal pericardial drainage was performed, with favorable postoperative outcomes.

Conclusion
Here, we report a rare case of gastro pericardial istula occurring without ulcer nor slipping of the wrap Nissen's fundoplication, the most usual factor implicated in the pathophysiologiology of this rare condition.Treatment included surgical transabdominal pericardial drainage, biopsy of the valve's defect, suture, and omentoplasty with a favorable postoperative course.The suspicion of gastro pericardial istula should be considered a rare differential diagnosis for acute chest pain in patients with a history of gastroesophageal surgery, even if the surgery occurred years before.Pneumocardium, as a delayed complication of antire lux surgery, is rare, and probably unrecognized.Recommended treatment includes surgical istula correction, as conservative management is associated with a worse prognosis.