Esophago-wrap fistula as a delayed complication of laparoscopic Nissen fundoplication: A case report and surgical management strategy

Introduction and importance

Laparoscopic anti-reflux surgery (ARS), particularly Nissen fundoplication, is an established and effective treatment for gastroesophageal reflux disease (GERD). Although generally safe, rare complications can arise, including esophago-wrap fistula a seldom-reported but serious postoperative sequela.

Case presentation

We report the case of a 51-year-old male with a history of laparoscopic Nissen fundoplication performed 20 years prior, presenting with halitosis, excessive burping, and chronic diarrhea. Diagnostic evaluation with endoscopy and contrast esophagography revealed a fistulous tract between the esophagus and the gastric fundus within the wrap. Surgical exploration confirmed esophago-wrap fistula along with a recurrent hiatal hernia, wrap slippage and dense adhesions. The fistula was resected using sequential black-load stapler cartridges due to thickened tissue, and a Toupet fundoplication was performed. The patient had an uneventful postoperative recovery with complete resolution of symptoms at six-month follow-up.

Clinical discussion

Esophago-wrap fistula is an exceptionally rare complication of ARS that may present with nonspecific gastrointestinal symptoms. Accurate diagnosis relies on a combination of endoscopic and radiologic modalities. Surgical intervention is the definitive treatment, often necessitating complex dissection, fistula resection, and redo fundoplication. This case underscores the importance of intraoperative vigilance and flexibility in surgical technique to manage rare but challenging complications. This case report has been reported in line with the SCARE checklist.

Conclusion

Esophago-wrap fistula is a rare but serious complication of anti-reflux surgery that requires a high index of suspicion and thorough diagnostic evaluation. Successful management depends on meticulous surgical planning, technical adaptability, and careful intraoperative execution.