Treating Complications Dysphagia, Leaks, Gastric Dysfunction Following Nissen Fundoplication Brant...

Treating Complications

Dysphagia, Leaks, Gastric DysfunctionFollowing Nissen Fundoplication

Brant K. Oelschlager, MDUniversity of Washington

CENTER FOR VIDEOENDOSCOPIC SURGERY


Postoperative Dysphagia

Improved17%

No change12%

Worse6%

Disappeared 65%

288 patients with 5 year follow-up

7 patients (2%) developed new dysphagia


Dysphagia

Early versus

Late


Dysphagia

Incidence Before Nissen – 43%

78% improved or resolved with Nissen New onset Dysphagia - 2% (Oelschlager BK, Am J Gastro 2007;102:1)

Causes Technical/anatomic factors Technical/anatomic factors Technical/anatomic factors Esophageal dysmotility


Dysphagia

Avoidance Proper operative technique Control of GERD Proper work-up Pre-operative Counseling

Treatment Supportive 3-4 months Dilation if persists Look hard for anatomic problems If all fails and no anatomic problem, revise to partial

fundoplication


Early Post-Operative Dysphagia

UGI or Endoscopy to r/o anatomic problem Patient tolerating liquids and can nourish and

hydrate In first 8-12 weeks – patience

More severe or more than 12 weeks Investigate further Consider dilation


Causes of Dysphagia

Recurrent Hiatal Hernia

Too Tight

Incorrect Orientation

Motility

Normal Post-operative Dysphagia


Type IA Hernia

GERD Occasionally Dysphagia

The Gastroesophageal Junction and the Wrap are Above the Diaphragm


Recurrent Hiatal Hernia

Acute herniation (first 7-10 days) should be treated with emergent operation

Others present more insidiously and can usually be managed electively


Causes of Recurrent Hiatal Hernia

Large Hiatal Hernia

Poor Closure

Short Esophagus

Obesity


Biologic Mesh Reinforced Repair


Recurrence Rate

0%

5%

10%

15%

20%

25%

Primary SIS

24%

9%*

* p = 0.04

Primary

SIS

UGI 6 Months After LPEHR


Short Esophagus

Sandone C. Ann Surg. 2000; 232:630-40

Collis Gastroplasty


Short Esophagus

Terry M. Am J Surg

2004; 188:195-99

WedgeGastroplasty


Obesity & Antireflux Surgery

Normal Overweight Obese

n (%) n (%) n (%)

Recurrence 4 (5%) 7 (8%) 15 (31%)

No Recurrence 85 (95%) 80 (92%) 33 (69%)*†

* P = 0.001 vs. obese † p < 0.0001 vs. normal

Perez AR, Surg Endosc 2002;16:1380.


Obesity & Antireflux Surgery

Morgenthal CB. Surg Endosc 2007.


Obesity and Antireflux Surgery

Anvari M, Surg Endosc 2006,20:230


Malpositioning


Fundoplication Too Tight

• Technique • Dilate, but wait if

possible


Type II Hernia

GERDDysphagiaor Both

Paraesophageal Hernia


Type III Hernia

DysphagiaOccasionally GERD

Malformation of the wrap. The body of the stomach is used to perform the fundoplication.


Proper Grasp for Fundoplication


(Video showing correct technique)


Symmetrical Repair


Non-Symmetrical Nissen


Motility Disorders

Important to diagnose underlying primary disorders pre-op

If primary disorder found post-op treat accordingly

** (Pic of Achalasia tracing)


Motility Disorders

Wait, Patience, Wait Dilate Revise to a Partial Fundoplication

Tracing of IEM


Dysphagia and Normal Anatomy & Function

Wait Patience Wait Dilate Wait Revise to a Partial Fundoplication


Management of Esophageal Leaks

Recognition Diagnosis Treatment


Recognition

Triad of Symptom – though rarely all three present until late

Chest Pain Persistent vomiting Sub-q emphysema

Non-iatrogenic perforations picked up late because diagnosis often not considered early

Three important things to note that drive management Location Underlying cause Time from insult to intervention


Diagnosis

CXR Can increase suspicion, but can’t rule in/out

UGI (best test) Diagnosis, severity, location

CT (being used more frequently) If can’t do UGI (Intubated, etc) Direct non-operative management

EGD (rarely) Maybe for management?


Treatment of Post-Surgical Leaks

Small, contained leaks

Antibiotics +/- drain and wait

Leaks occurring and recognized in the first 24 - 48 hours

Consider laparoscopic reoperation, primary closure and buttress

Late occurring


Self-Expanding Plastic Stent(SEPS)Self-Expanding Plastic Stent(SEPS)

Similar to SEMS in Concept Radial Expansile Force Less

than SEMS Causes Less Trauma than

SEMS Can be Repositioned or

Removed Indications:

Refractory benign and malignant strictures

Intrinsic or extrinsic lesions Esophageal-respiratory fistula

Polyflex®


ResultsResults

Clinical Outcome No. pts

Relief of dysphagia allowing oral feeding 27/39 (69%)

Sealing of esophageal leakage 11/15 (73%)

Stent dysfunction 6/39 (15%)

Stent migration 8/39 (20%)

Re-intervention 14/39(36%)

Stent removal b/o intolerability 5/39 (13%)

Radecke et al. Gastrointest Endosc 2005; 61:812-818


Endoscopic TherapyEndoscopic TherapyMetallic Stents Plastic Stents

• Role still evolving•Possibly for large leak effectively drained• No control studies - don’t know denominator or how many would heal on their own


Gastric Dysfunction


28 patients (<10%) develop new bloating

Bloating/Gastric Bloating/Gastric DysfunctionDysfunction

150

3

17 18

-12

38

88

138

188

238

288

Severity

0

1

2

3

4

5

6

7

8

9

10

150

3

17 18

-12

38

88

138

188

238

288

Severity

0

1

2

3

4

5

6

7

8

9

10

Bloating severity postop Now compared to before operation

Better(n=69)

Worse(n=78)

Same(n=41)


Bloating

Incidence

18% before surgery 12% after surgery (Oelschlager BK, Am J Gastro 2007;102:1)

19% after (Klaus A, Am J Med 2003;114:6.)

Causes

Underlying gastroparesis

Air swallowing

Vagal nerve injury

Associated IBS (~66%) and overlapping GI diseases


Bloating

Avoidance

Avoid Vagal trauma (Including nerve of Laterjet)

Pre-operative Counseling

Beware of associated IBS

Treatment

Recognition

Supportive

Rarely, if ever, perform surgical gastric emptying

Endoscopic pyloric dilation or Botox

Potentially convert to partial fundoplication


The Role of Pre-op Gastric Emptying Studies


Improvement in Gastric Emptying with Fundoplication


Effectiveness of Empyting Procedures for Gastroparesis

CENTER FOR VIDEOENDOSCOPIC SURGERYCopyright restrictions may apply.

Watson, D. I. et al. Arch Surg 2004;139:1160-1167.

Less Bloating with Partial Fundoplication?


Strategy Post-op Gastric Dysfunction

Based on Severity Work-up

Gastric Emptying – documentation UGI – Function and fundoplication anatomy Manometry – associated motor disorders 24-hour pH - ? Reflux control

Options Emptying Procedure Partial Fundoplication Gastrectomy


“Before we consider assisted suicide, Mrs. Jones, let’s give the Prilosec a chance”

Treating Complications Dysphagia, Leaks, Gastric Dysfunction Following Nissen Fundoplication Brant...

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