A Tale of Management of Post Fundoplication Esophageal Perforation with Esophago-pleural Fistula: A Case Report

Abstract

Background: Esophageal perforation following laparoscopic fundoplication is uncommon but potentially life-threatening because of pleural or mediastinal contamination, sepsis, and respiratory compromise. Early recognition, adequate drainage, and prompt source control are essential. Selected stable patients may benefit from individualised multidisciplinary management. Case Presentation: A 32-year-old woman without any comorbidities presented with dyspepsia and heartburn for two years. Ultrasonography and CECT of the abdomen were normal, while upper gastrointestinal endoscopy showed a Hill grade III hiatus hernia. She underwent laparoscopic fundoplication. On postoperative day 1, she developed tachycardia and tachypnoea, and chest radiography showed a right-sided hydrothorax. A right intercostal drain was inserted. CECT subsequently demonstrated an esophageal perforation near the gastroesophageal junction communicating with the right pleural cavity. Surgical re-exploration was performed, with primary repair reinforced by an omental pedicle flap and creation of a feeding jejunostomy. Persistent bilious drainage was subsequently managed with drainage, antimicrobial therapy, nutritional support, enteral feeding through the jejunostomy, and close surveillance. The fistula gradually resolved over approximately two months, with imaging and endoscopy confirming healing. Discussion: Unexpected respiratory deterioration after fundoplication should prompt consideration of esophageal injury. In a clinically stable patient with adequate drainage and no uncontrolled sepsis, persistent leakage may be managed conservatively with nutritional diversion and close monitoring after appropriate source control. Conclusion: Early diagnosis, effective drainage, nutritional optimisation, and individualised multidisciplinary care are central to the successful management of post-fundoplication esophageal perforation.