Treating Complications

Dysphagia, Leaks, Gastric DysfunctionFollowing Nissen Fundoplication

Brant K. Oelschlager, MDUniversity of Washington

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Postoperative Dysphagia

Improved17%

No change12%

Worse6%

Disappeared 65%

288 patients with 5 year follow-up

7 patients (2%) developed new dysphagia

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Dysphagia

Early versus

Late

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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

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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

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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

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Causes of Dysphagia

Recurrent Hiatal Hernia

Too Tight

Incorrect Orientation

Motility

Normal Post-operative Dysphagia

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Type IA Hernia

GERD Occasionally Dysphagia

The Gastroesophageal Junction and the Wrap are Above the Diaphragm

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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

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Causes of Recurrent Hiatal Hernia

Large Hiatal Hernia

Poor Closure

Short Esophagus

Obesity

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Biologic Mesh Reinforced Repair

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Recurrence Rate

0%

5%

10%

15%

20%

25%

Primary SIS

24%

9%*

* p = 0.04

Primary

SIS

UGI 6 Months After LPEHR

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Short Esophagus

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

Collis Gastroplasty

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Short Esophagus

Terry M. Am J Surg

2004; 188:195-99

WedgeGastroplasty

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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.

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Obesity & Antireflux Surgery

Morgenthal CB. Surg Endosc 2007.

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Obesity and Antireflux Surgery

Anvari M, Surg Endosc 2006,20:230

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Malpositioning

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Fundoplication Too Tight

• Technique • Dilate, but wait if

possible

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Type II Hernia

GERDDysphagiaor Both

Paraesophageal Hernia

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Type III Hernia

DysphagiaOccasionally GERD

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

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Proper Grasp for Fundoplication

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(Video showing correct technique)

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Symmetrical Repair

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Non-Symmetrical Nissen

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Motility Disorders

Important to diagnose underlying primary disorders pre-op

If primary disorder found post-op treat accordingly

** (Pic of Achalasia tracing)

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Motility Disorders

Wait, Patience, Wait Dilate Revise to a Partial Fundoplication

Tracing of IEM

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Dysphagia and Normal Anatomy & Function

Wait Patience Wait Dilate Wait Revise to a Partial Fundoplication

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Management of Esophageal Leaks

Recognition Diagnosis Treatment

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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

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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?

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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

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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®

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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

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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

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Gastric Dysfunction

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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)

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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

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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

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The Role of Pre-op Gastric Emptying Studies

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Improvement in Gastric Emptying with Fundoplication

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Effectiveness of Empyting Procedures for Gastroparesis

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

Less Bloating with Partial Fundoplication?

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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

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