Acute management of hydropneumothorax secondary to esophageal perforation after laparoscopic fundoplication

Background Laparoscopic fundoplication is commonly performed for refractory gastroesophageal reflux disease and symptomatic hiatal hernia, but rare postoperative complications such as esophageal perforation may result in significant morbidity and mortality if not promptly recognized. Case report We present a case of esophageal perforation complicated by massive hydropneumothorax in a woman who presented to the emergency department with progressive chest pain, abdominal pain, and respiratory distress two weeks after hiatal hernia repair with Nissen fundoplication. Emergent tube thoracostomy performed in the emergency department drained a large volume of purulent fluid and resulted in immediate respiratory improvement. Computed tomography with oral contrast subsequently demonstrated distal esophageal perforation with associated mediastinitis. The patient underwent operative management by the cardiothoracic surgery team and recovered well, ultimately being discharged home in stable condition two weeks later. Why should an emergency physician be aware of this? Patients frequently present to the emergency department with postoperative complications. Emergency physicians must be able to promptly recognize and stabilize an esophageal perforation, as delayed diagnosis and treatment are associated with significant morbidity and mortality.