Complications Following Antireflux Surgery: Recognition and Management
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Complications Following Antireflux Surgery: Recognition and Management

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    Complications Following Antireflux Surgery: Recognition and Management Complications Following Antireflux Surgery: Recognition and Management Presentation Transcript

    • 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)
      • Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006; 244: 42-51.
      • 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
      • Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006; 244: 42-51.
      • 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
      • Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006;244: 42-51.
      • 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 Iqbal et al. 104 failed anti-reflux procedures Iqbal et al. Reoperation for Failed Anti-Reflux Surgery. Ann Surg 2006; 244: 42-51. Mechanism of failure % of pre-operative predictability Crus 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
    • 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 criteria
      Iqbal et al. Reoperation for failed anti-reflux surgery. Ann Surg 2006;244: 42-51. Not exceed 2cm for laparoscopy
    • Re-operative management
      • Fundoplication inefficacy
        • Too tight or too loose
        • Twisted wrap
        • Telescoping
        • Complete or partial disruption
        • Management:
        • Dismantling the fundoplication
          • Mobilization and division of short gastrics
        • Redo fundoplication
          • Toupet if wrap is too tight
          • 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
        • Achalasia
        • Management: Heller myotomy
        • Barrett’s/carcinoma
        • Management: Esophagectomy
        • Gastroparesis
        • Management: Pyloroplasty
        • Esophageal dysmotility
        • Management: 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° surgery
      • 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.
      • 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
        • RECOGNITION
        • AND
        • MANAGEMENT
        • OF
        • 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
          • CO 2 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.