Iatrogenic cardiac tamponade as a mortal complication of peri-hiatal surgery. Analysis of 30 published cases

Iatrogenic Causes of Cardiac Tamponade Resulting From Surgical Procedures: An Overview

Cardiac tamponade is one of the most severely life-threatening emergencies encountered, mainly because of its significant impact on the pumping capacity of the heart by compressing the cardiac chambers due to the rapid accumulation of blood, fluid, pus, or clots in the pericardial sac. These accumulations may be collected following traumas, malignancies, uremia, and many other medical conditions as well as surgical procedures. Numerous errors and medicolegal aspects have been identified in diagnosing and treating cardiac tamponade associated with cardiac-related procedures such as valve replacement surgeries, cardiac pacemaker implantation, pericardiocentesis, and other non-cardiac related procedures such as peri-hiatal surgeries. Patients taking anticoagulants or anticancer medications are especially susceptible to developing cardiac tamponade when undergoing surgical procedures, raising the question of preoperative screening to avoid errors. Misdiagnosis, treatment delay or failure to deliver the utmost quality of treatment, lack of complication screening and follow-ups for those at risk, surgeons rushing to complete cases, burnout, and other human factors are predispositions to the development of cardiac tamponade. Fortunately, most of these errors occurring within healthcare settings are avoidable and must be prevented for eliminating any risks to reduce the incidence and mortality of cardiac tamponade cases resulting from iatrogenic etiology. It is an intricate condition where precision and caution are crucial.

Preoperative calculation of angles of vision and working area in laparoscopic surgery to treat a giant hiatal hernia

BACKGROUND

Giant hiatal hernias still pose a major challenge to digestive surgeons, and their repair is sometimes a highly complex task. This is usually performed by laparoscopy, while the role of the thoracoscopic approach has yet to be clearly defined.

AIM

To preoperatively detect patients with a giant hiatal hernia in whom it would not be safe to perform laparoscopic surgery and who, therefore, would be candidates for a thoracoscopic approach.

METHODS

In the present study, using imaging test we preoperatively simulate the field of vision of the camera and the working area (instrumental access) that can be obtained in each patient when the laparoscopic approach is used.

RESULTS

From data obtained, we can calculate the access angles that will be obtained in a preoperative computerised axial tomography coronal section, according to the location of the trocar. We also provide the formula for performing the angle calculations If the trocars are placed in loss common situations, thus enabling us to determine the visibility and manoeuvrability for any position of the trocars.

CONCLUSION

The working area determines the cases in which we can operate safely and those in which certain areas of the hernia cannot be accessed, which is when the thoracoscopic approach would be safer.

[Mesh Implantation in Anti-Reflux and Hiatal Hernia Surgery - Contra Statement]

In the surgical treatment of gastroesophageal reflux disease and of hiatal hernias, the high rate of recurrence of hiatal hernias is a central problem. Against this background, various, primarily alloplastic, meshes are used to augment suture closure on the esophageal hiatus. Very different results have been reported in the past and the use of meshes in hiatus reconstruction is controversial. In addition to the frequency of recurrences, reports about complications of mesh augmentation are in the foreground. On the basis of several prospective randomised double-blinded comparative studies and meta-analyses (class Ia and Ib evidence), the current data do not show any advantages of mesh-augmented hiatoplasty for the prevention of recurrence of hiatal hernia. At the same time, there exist reports of more long-term postoperative complications, especially dysphagia, after use of meshes for augmentation of hiatus reconstruction. Therefore, routine use of mesh augmentation for hiatus reconstruction is currently not recommended.

Delayed pericardial tamponade following central venous recanalization

A patient with central venous occlusion at the junction of the superior vena cava and right atrium underwent endovascular revascularization. The leakage of contrast agents was detected during sharp recanalization that was then managed with covered stent deployment. The initial symptom of facial swelling disappeared and the vital signs were stable after treatment. Regrettably, the patient suffered from the clinical features of cardiac tamponade on the third day post-treatment, which was confirmed by computed tomography. Finally, a pericardial effusion was drained, leading to dramatic improvement in the cardiovascular status of the patient.

Cardiac Tamponade by Tack Fixation of a Hiatal Mesh. Should Tacks Still Be Used in the Diaphragm?

Since the first successful use of mesh in hernia surgery, the development and progress in materials, techniques, and procedures have increased exponentially; consequently, surgeons started to use meshes for hiatal hernia repair to prevent postoperative hernia recurrences and complications. Nonetheless, there are alarming reports in literature concerning cardiac tamponade as an apparently rare complication of hiatal mesh placement, especially when fixation is performed with tacks.

A 50-year-old female diagnosed with gastroesophageal reflux disease undergoes an elective laparoscopic Nissen fundoplication and hiatal hernia repair with tack fixation of the mesh; on the fourth postoperative day she was readmitted with cardiac tamponade diagnosed via echocardiography, and CT scan showed proximity of the tacks to the pericardium. She underwent a failed attempt of ultrasound guided pericardiocentesis (PC), therefore, a pericardial window was performed.

The ideal method for diaphragmatic mesh fixation is still controversial. Some recent articles alert of this potential risk; although the manufacturers contraindicate the use of tacks in the diaphragm, one-third of surgeons prefer this method.