Complications Following Antireflux Surgery:

Recognition and Management

George Ferzli, MD, FACS

Anti-reflux surgery

• 1945 to present–Multiple methods and techniques:

• Nissen fundoplication• Dor wrap• Hill gastropexy ….

–Different approaches:• Laparotomy vs laparoscopy• Thoracotomy vs thoracoscopy

Rudolph Nissen, MD

INFLUENTIAL PEOPLE:

Lortat-Jacob, MD

AndreToupet, MD

Jacques Dor, MD

Ernst Heller, MD

Rudolph Nissen MD

Ivor Lewis, MD

J. Leigh Collis, MD

K. Alvin Merendino, MD

Lucius Hill, MD

Ronald Belsey, MD

Alan Thal, MD

Intra-operative complications

Pleura / lung breech during hiatal dissection

Intra-operative complications• Hemorrhage

– Short gastric vessels– Spleen– Liver retraction– Left inferior phrenic vein– Aberrant left hepatic vein– IVC– Cardiac tamponade from right ventricular

trauma (please remember that metal tacks could cause hemmoragic tamponade )

Post-operative complications

MEDICAL– Infectious– Pulmonary– Urinary infection– Arrhythmia

SURGICAL– Inadvertent vagus division – Leakage from GI tract – Subdiaphragamatic abscess

– Splenic upper pole devascularization

– Failed fundoplication repair

– Fistulas

Fistulas

• Gastro-bronchial fistulas– Intra-thoracic “slipped” wrap– 2° to gastric ulceration– Perigastric abscess– Erosion into bronchus

• Gastro-aortic fistulas

• Gastro-pericardial fistulas

Fistulas• Presentation

– Lower lobe abscess– Gastric contents

expectoration– Cough on lying down

• Diagnosis– UGI Series– Methylene blue staining– Measurement of bronchial

secretion pH

• Management– Control sepsis– Drainage– Division of fistula with or w/o

resection of affected organ– Delayed re-fashioning of diaphragm

and fundoplication

Failed anti-reflux surgery

Failure rate– Open fundoplication: 9% to 30%– Laparoscopic: 2% to 17%

When faced with failure:– Evaluate symptoms– Extensive workup

Failed antireflux symptoms

• Dysphagia• Regurgitation• Heartburn• Chest pain• Pulmonary symptoms• Nausea / vomiting• Abdominal bloating

• Make sure to obtain and review the old operative report

Pre-operative work-up• Esophagram

– Evaluate proximal and distal esophagus

– Estimate the size of the hiatal hernia

– May help diagnose a shortened esophagus (<5cm)

1. Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006; 244: 42-51.2. Furnée et al. Surgical Reintervention after Antireflux Surgery for Gastroesophageal Reflux

Disease: A prospective cohort study in 130 patients. Arch Surg 2008;143(3): 267-274.

GE junction

Confluence of diaphragm

Top of mediastinal gastric tissue

Not exceed 5cm for laparoscopy

Not exceed 2cm for

laparoscopy

Pre-operative work-up• EGD

– Determines presence or absence of cancer

– Direct inspection and biopsy….. BARRETT’S

– Peptic strictures, ulcers

– Size of hiatus

– Presence of food in stomach

– Location and tightness of fundoplication (dilator)

– Length of gastric tissue above fundoplication

– Presence of disrupted fundoplication

1. Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006; 244: 42-51.2. Furnée et al. Surgical Reintervention after Antireflux Surgery for Gastroesophageal Reflux

Disease: A prospective cohort study in 130 patients. Arch Surg 2008;143(3): 267-274.

Pre-operative work-up• Manometry

– Assessment of esophageal relaxation– Esophageal body dysmotility and wave amplitude– May help assessing fundoplication pressure– LES function and positioning

• pH Monitoring– If esophagitis on EGD

• Gastric emptying studies– If previous vagotomy– Old food regurgitation– Food within stomach at EGD after fasting

1. Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006;244: 42-51.2. Furnée et al. Surgical Reintervention after Antireflux Surgery for Gastroesophageal Reflux

Disease: A prospective cohort study in 130 patients. Arch Surg 2008;143(3): 267-274.

Predictability of mechanism of failure

Mechanism of failure % of pre-operative predictabilityCrus closure failure 96

Hiatal stenosis 20

Partial fundoplication disruption 86

Complete fundoplication disruption 86

Hypertensive fundoplication 92

Slipped fundoplication 89

Loose fundoplication 50

Short esophagus 37

Gastroparesis 100

Iqbal et al. 104 failed anti-reflux procedures

Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006; 244: 42-51.

Additional causes of failure

Wrong 1° Dx– Achalasia– Dysmotility– Carcinoma– Gastroparesis – Inadvertent vagotomy– Funnel stomach

Operative approach

• Open thoracotomy– Recommended when > 2 cm of

gastric tissue within thoracic cavity on esophagram

– Short esophagus suspected

• Laparotomy– Multiple previous failed

operations

• Laparoscopy– Patient did not meet above

criteriaIqbal et al. Reoperation for failed anti-reflux surgery. Ann Surg 2006;244: 42-51.

Not exceed 2cm for laparoscopy

Re-operative managementFundoplication inefficacy

– Too tight or too loose– Twisted wrap– Telescoping– Complete or partial disruption

Management: 1. Dismantling the fundoplication

a. Mobilization and division of short gastrics

2. Redo fundoplicationa. Toupet if wrap is too tightb. Dor if no esophageal peristalsis

Tuomo et al. Complications in Antireflux Surgery: National-Based Analysis of Laparoscopic and Open Fundoplications. Arch Surg 2008;143: 359-365.

Re-operative management

• Crus closure failure– Interrupted non-absorbable sutures– Mesh reinforcement

• Granderath et al– 24 patients with failed antireflux surgery– Circular hiatal mesh @ re-operation– 6% recurrence rate after 5 years– Improved functional parameters

• DeMeester scores• LES pressure

– Improved quality of life

Granderath et al. Laparoscopic Revisional Fundoplication with Circular Hiatal Mesh Prosthesis: The Long-Term Results. World J Surg 2008; 32: 999-1007.

Polypropylene mesh

Esophagus

• Do not use metal tacks

• Biologic mesh? dual mesh?

• No mesh at all? (remember original Toupet repair)

Mesh

Wrap

Circular mesh

Fundoplication

• Esophageal shortening– Skeletonized GEJ not easily reduced– At least 2 cm into peritoneal cavity in open

surgery and at least 3 cm for laparoscopy

• Management– Collis at least 4-5cm long (gastroplasty tube

from stomach)– Merendino (interposition of 15 cm small

bowel segment of jejunum between esophagus and stomach)

• Disadvantage– Neo-esophagus secretes acid– May lead to recurrent reflux or PUD

Re-operative management

Collis

4cm

Re-operative management• Wrong 1° diagnosis

– AchalasiaManagement: Heller myotomy

– Barrett’s/carcinomaManagement: Esophagectomy

– GastroparesisManagement: Pyloroplasty

– Esophageal dysmotilityManagement: Dor, or Toupet

Khajanchee et al. Laparoscopic Reintervention for Failed Antireflux Surgery. Arch Surg 2007;142(8): 785-792

Pitfalls• Collis gastroplasty should be done on 48 French

• Intraoperative perforations must be closed with sutures incorporating mucosa

• Must have intraoperative EGD during surgery

• Must use 60 bougie, it will allow a good asessment of the mobility of the fundic wrap and secure an adequate fundoplication

• Must ligate and divide short gastric vessels

• Do not hesitate to convert from laparoscopy to open

Complications and results after re-operation• Re-operation failure rate = 20% to 30%

• Inadequate crus closure

• Fundoplication disruption

• Influencing factors:– Collagen deficiency?– Hidden role of the patient

• Uncontrolled vomiting• Retching• Lifting

• Results after re-do surgery are worse than after 1° surgery1. Furnée et al. Surgical Reintervention after Antireflux Surgery for Gastroesophageal Reflux

Disease: A prospective cohort study in 130 patients. Arch Surg 2008;143(3): 267-274.2. Furnée EJB et al. Surgical Reintervention After Failed Antireflux Surgery: A Systematic

Review of the Literature. J Gastrointest Surg 2009. Published online ahead of print

Summary• Re-operative antireflux surgery

is feasible, difficult, but effective.

• Surgical approach should be tailored to suspected mechanism of failure using extensive pre-operative workup.

• Adequate mobilization and fundoplication dismantling are of utmost importance.

• Surgeon’s experience plays critical role in choice of re-operative approach.

Anti-reflux Surgery

RECOGNITIONAND

MANAGEMENTOF

COMPLICATIONS

Anti-reflux Surgery

• Multiple unanswered questions:– Role of laparoscopy

• As initial intervention• Redo

– Need for esophageal lengthening– Efficacy of partial fundoplication– Endoluminal therapy

Intra-operative complications

• Pulmonary– Pneumothorax / Pneumomediastinum

• Breach of pleura during hiatal dissection• Relieved by tube thoracostomy

– Pneumoperitoneum• CO2 rapidly dissipates after release

– Positive pressure ventilation– Absorption

Indications for Re-operation• Surgically correctable disorder

• Not amenable to medical management

• Furnée et al: Review of multiple studies – Pre-operative symptoms assessed by questionnaire– Work-up:

• EGD• Barium swallow• pH monitoring

Furnée EJB et al. Surgical Reintervention After Failed Antireflux Surgery: A Systematic Review of the Literature. J Gastrointest Surg 2009. Published online ahead of print

Re-operative management

• Initial laparoscopic approach– Prone to higher recurrence of dysphagia

– 15 patients with severe dysphagia after laparoscopic approach

None had short gastric vessel division during initial surgery!!!

Tuomo et al. Complications in Antireflux Surgery: National-Based Analysis of Laparoscopic and Open Fundoplications. Arch Surg 2008;143: 359-365.