CLINICAL SPOTLIGHT

Clinical Spotlight

Pericardial Tamponade: A Life Threatening

Complication of Laparoscopic Gastro-oesophageal
Surgery
Hariharan Sugumar, BMedSc, MBBS a,∗ , Leighton G. Kearney, BMedSc, MBBS,
FRACP a,b and Piyush M. Srivastava, MBBS, FRACP, FCSANZ a,b
a Department of Cardiology, University of Melbourne, Austin Health, Australia
b Department of Medicine, University of Melbourne, Austin Health, Australia

Laparoscopic surgical procedures involving the gastro-oesophageal region are commonly performed for the manage-
ment of morbid obesity and refractory gastro-oesophageal reflux disease (GORD). In general, laparoscopic procedures
are associated with lower morbidity and mortality in comparison with open techniques. This report highlights cases of
potentially life threatening, late onset pericardial tamponade, occurring in the absence of infection or trauma, compli-
cating laparoscopic gastro-oesophageal surgery. Possible mechanisms, clinical manifestations, diagnostic investigations
and management of pericardial tamponade are reviewed.
(Heart, Lung and Circulation 2012;21:237–239)
Crown Copyright © 2011 Published by Elsevier Inc. on behalf of Australian and New Zealand Society of Cardiac and
Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.
Keywords. Percardial tamponade; Sympathetic effusion; Laparoscopic surgery complications; Postoperative chest pain

Introduction dial complications without infection or a direct fistulous

L aparoscopic surgical procedures involving the stom-
ach and lower oesophageal junction are commonly
performed for the management of morbid obesity and
refractory gastro-oesophageal reflux disease (GORD). In
general, the morbidity and mortality of laparoscopic
surgery is significantly lower than open techniques [1].
Laparoscopically assisted gastric banding (LAGB) has a
mortality of 0.05% [2] and a late complication rate of 11%,
predominantly due to device related issues [2,3]. Laparo-
scopic anti-reflux surgery, such as Nissen fundoplication,
also has a low post-operative complication rate of 2.6%
with negligible procedure-related mortality [1,4].
There are sporadic reports of pericardial complica-
tions related to laparoscopic gastro-oesophageal surgery
in the literature. Complications secondary to infection or
direct trauma such as pericardiotomy-like syndrome [5]
and gastro-pericardial fistula [6] have been reported. Bui
et al. postulated “sympathetic” pericardial effusion sec-
ondary to an infected LAGB system in 2003 [7]. To the
authors’ knowledge, there have been no reports of pericar-
Received 4 May 2011; received in revised form 17 July
2011; accepted 2 August 2011; available online 1 September 2011
∗ Corresponding author at: Austin Hospital, 145 Studley Road, PO
Box 5555, Heidelberg, Victoria 3084, Australia.
Tel.: +61 3 9496 5000; fax: +61 3 9459 0971.
E-mail addresses: hariharan.sugumar@austin.org.au
(H. Sugumar), Leighton.kearney@austin.org.au (L.G. Kearney),
piyush.srivastava@austin.org.au (P.M. Srivastava).
Crown Copyright © 2011 Published by Elsevier Inc. on behalf of Australian and New
Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society
of Australia and New Zealand (CSANZ). All rights reserved.
communication from laparoscopic gastro-oesophageal
surgery. We report two cases of life threatening cardiac
tamponade, presenting as a late complication of laparo-
scopic surgery involving the stomach and low oesophagus
without evidence of infection or trauma. Both cases
required urgent surgical intervention with pericardiotomy
and drainage.
Case Study 1
A 63 year-old woman with morbid obesity (140 kg)
and Barrett’s oesophagus underwent an elective LAGB
and reduction of hiatus hernia (Bard® -composix® -E/X-
mesh). Her early recovery was complicated by atrial
fibrillation (AF) and acute pulmonary oedema. Trans-
thoracic echocardiography (TTE) performed on day 4
post-operatively, demonstrated a small to moderate peri-
cardial effusion (maximal dimension 2.6 cm) without
features of tamponade. She was treated conservatively
with commencement of amiodarone for AF without anti-
coagulation.
In the post-operative period, the patient had recurrent
presentations to the emergency department with chest
pain and rapid AF but displayed no clinical evidence
of cardiac tamponade and was managed conservatively.
Five weeks post-surgery, she represented with chest pain,
hypotension (103/60 mm Hg), distended neck veins and
muffled heart sounds. Chest X-ray demonstrated globular
1443-9506/04/$36.00
doi:10.1016/j.hlc.2011.08.002
 238 Sugumar et al.
CLINICAL SPOTLIGHT
Pericardial tamponade & laparoscopic upper GI surgery
Figure 1. Chest X-ray demonstrating cardiomegaly with poor
visualisation of the left costophrenic sulcus.
cardiomegaly (Fig. 1). Inflammatory markers were ele-
vated (leucocytes 12.4 × 109 L−1 , neutrophils 9.0 × 109 L−1 ,
C-reactive protein was 306 mg L−1 ). A computed tomog-
raphy pulmonary angiogram (CTPA) revealed a large
pericardial effusion (Fig. 2). TTE confirmed a large
global pericardial effusion (maximal thickness 3.8 cm)
with evidence of cardiac tamponade. The patient under-
went urgent drainage of the effusion via a lower third
mini hemi-sternotomy. Microbiological analysis of the
pericardial fluid excluded an infective or haemorrhagic
Figure 2. Chest computed tomography (axial view) demonstrating a
pericardial effusion and the close proximity of the surgical material
(white long arrow) to the pericardium (white short arrow).
Heart, Lung and Circulation
2012;21:237–239
Figure 3. Chest computed tomography (coronal view) demonstrating
a small pericardial effusion and the close proximity of the surgical
material (three white arrows) to the pericardium.
aetiology. Post-drainage TTE demonstrated no recurrence
of the pericardial effusion. The patient subsequently made
excellent progress with weight loss of 60 kg and no further
cardiac symptoms.
Case Study 2
A 75 year-old woman with history of pulmonary embolism
(PE) requiring lifelong anticoagulant therapy underwent
an uncomplicated laparoscopic hiatus hernia repair with
mesh (GORE® dual-mesh) and loose Nissen fundopli-
cation for treatment of symptomatic para-oesophageal
hernia with gastric volvulus.
Thirteen days post-surgery, the patient presented to the
emergency department with chest pain. A ventilation-
perfusion lung scan demonstrated a low probability
of PE and the patient was discharged with analgesia.
She re-presented on the same day with severe pleuritic
chest pain. Electrocardiography (ECG) demonstrated new
widespread concave ST segment elevation. An urgent
TTE revealed normal cardiac function but demonstrated
a small circumferential pericardial effusion without evi-
dence of tamponade. Chest computed tomography (CT)
performed to exclude surgical complications, but con-
firmed a small pericardial effusion (Fig. 3). The patient
was diagnosed with acute pericarditis and commenced
on non-steroidal anti-inflammatories and colchicine. She
remained haemodynamically stable and was discharged
four days later with follow-up echocardiography organ-
ised. Anticoagulation was recommenced four weeks after
surgery.
Thirty-seven days post-surgery, the patient repre-
sented to hospital with worsening dyspnoea and reduced
Heart, Lung and Circulation
2012;21:237–239
exercise tolerance. Physical examination revealed raised
neck veins and peripheral oedema with audible heart
sounds. She was haemodynamically stable and afebrile.
TTE showed a moderate pericardial effusion with right
atrial compression, an early sign of compromised car-
diac filling. A repeat TTE three days later demonstrated
increased pericardial fluid accumulation with Doppler
and 2D features of cardiac tamponade. The patient
underwent pericardial drainage with creation of a peri-
cardial window from the sub-xiphoid approach. The
pericardial fluid was blood stained without evidence of
infection. Findings were consistent with haemorrhagic
transformation of the effusion. Her preceding coagula-
tion studies demonstrated therapeutic, but not excessive
anticoagulation.
Follow-up echocardiography demonstrated no recur-
rence of the pericardial effusion. The patient has
remained well with resolution of gastrointestinal symp-
toms.
Discussion
Chest discomfort following gastro-oesophageal surgery
represents a difficult and diagnostic challenge. These
cases highlight that pericarditis with associated peri-
cardial effusion is an important and potentially life
threatening complication of laparoscopic gastro-
oesophageal surgery and should be considered
alongside standard surgical complications and pul-
monary thromboembolism. Significant pericardial
effusions can rapidly progress to life threatening
pericardial tamponade characterised by hypotension,
tachycardia, pulsus paradoxus, Kussmaul’s sign and
distant or absent heart sounds. Early cardio-thoracic
imaging with chest CT and/or TTE is essential in cases
of unexplained or persistent post-procedural chest
discomfort.
Pericardial effusions may complicate pericarditis in
the acute or late post-operative phase. Once identi-
fied, monitoring for progressive fluid accumulation and
tamponade is essential. Potential mechanisms for the
development of a pericardial effusion following gastro-
oesophageal surgery include: direct pericardial trauma,
spread of infection from implanted prosthetic mate-
rial and “sympathetic” pericarditis with effusion [5–7].
Sympathetic pericarditis may result from reactive peri-
cardial inflammation in response to foreign material in
close proximity to the pericardium and from pericardial
trauma related to the surgical procedure. Therapeu-
tic anticoagulation or other bleeding diatheses may
precipitate haemorrhagic transformation of an existing
pericardial effusion or cause a primary haemorrhagic
effusion.
Sugumar et al. 239
CLINICAL SPOTLIGHT
Pericardial tamponade & laparoscopic upper GI surgery
In these case studies, an infectious cause was excluded
by pericardial fluid analysis and direct pericardial trauma
is unlikely given the delayed presentations. Figures 2 and 3
demonstrate the proximity of the pericardium to the
surgical field supporting the hypothesis for a reactive sym-
pathetic process, with case two undergoing secondary
haemorrhagic transformation despite the absence of doc-
umented excessive anticoagulation.
The management of a pericardial effusion is dependent
upon its size and haemodynamic consequences. Pericar-
dial drainage with minimally invasive pericardiocentesis
or open pericardiotomy should be performed emergently
in patients with pericardial tamponade. For diagnostic
purposes, drainage of large asymptomatic effusions may
also be indicated. Laboratory analysis of the pericardial
fluid is essential to identify the underlying aetiology.
Although a percentage of patients with reactive pericar-
dial effusion may resorb over time, once identified, a
repeat echocardiography is recommended within one to
two weeks to determine if there is progression or echocar-
diographic evidence of tamponade even in the absence of
clinical deterioration or signs of progression. This is partic-
ularly important in patients requiring anticoagulation for
coexisting conditions such as AF, mechanical heart valves
and pulmonary emboli.
In conclusion, late onset pericardial tamponade is a
rare but important complication of laparoscopic gastro-
oesophageal surgery. Early recognition and prompt
management of this complication is essential to avoid
associated morbidity and mortality.
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