Fundoplication

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The causation of lower esophageal sphincter incompetence that can lead to gastroesophageal reflux is multifactorial. The list may include transient lower esophageal sphincter (LES) relaxation not related to a swallow, decreased resting tone of the LES, gastric motility disturbances, and distortion of the gastroesophageal junction anatomy (lack of a flap valve mechanism) [128]. The relationship of reflux and the presence of a hiatal hernia is unclear.

The surgical management of gastroesophageal reflux is based on restoration of competency of the valve. To achieve this goal, six basic principles must be met [128]:

1. The distal esophagus must be wrapped by a fundoplication that is affixed to the esophagus to keep it in place.

2. No tension can be placed on the fundoplication.

3. The esophagus must allow the passage of a large bougie (~55-60F).

4a. The plication should be 2 cm long anteriorly, and slightly longer posteriorly if a complete wrap is performed. 4b. If a partial fundoplication is performed (as described shortly) it should be 3 to 4 cm long.

5. The wrapped portion of the esophagus must be subdiaphragmatic in position.

6. The diaphragmatic hiatus must be narrowed about the esophagus proximal to the level of the wrap.

Many variations of fundoplication have been proposed and utilized. They all try to balance adequate reflux control without excessive dysphagia [129]. As described by Stirling and Orrinqer [130], Nissen originally proposed a complete, 360° wrap with the gastric fundus wrapped posteriorly, to the right, and then anteriorly to encompass the entire circumference of the distal esophagus. Eventually, this wrap was shortened from 4 to 5 cm to approximately 2 cm, the wrap was performed over a large-bore dilator, and the short gastric vessels were divided to prevent traction on the fundoplication. These measures effectively loosened the fundoplication, and the procedure has been termed a floppy fundoplication (Fig. 2.36).

If there is insufficient length of esophagus to allow a subdiaphrag-matic wrap to be performed without undue tension on the fundopli-cation, a Collis gastroplasty may be performed [70,128,131,132]. This procedure, which is often performed with the following techniques, effectively lengthens the abdominal portion of the esophagus. It is performed by dividing the stomach along the lesser curvature just lateral to the left border of the distal esophagus with a GI stapling device. A large bougie is placed in the esophagus as a guide and to prevent inadvertent narrowing of the tube created [128,131,132].

Toupet, Dor, Skinner and Belsey, and Hill have made further modifications to the original technique. Toupet modified the Nissen wrap by making it incomplete, only encompassing the posterior wall of the esophagus and attaching the fundoplication to the anterior wall

Modified Dor Procedure
Figure 2.36. Nissen fundoplication. Schematic drawing of a Nissen fundoplication.

of the esophagus and the diaphragmatic hiatus, which is not closed [128,131].

Dor reversed the Toupet procedure, encompassing the anterior wall of the distal esophagus [128,131] (Fig. 2.37). This approach may be used following a lower esophageal myotomy, in which the wrap covers the myotomy site [128].

The Belsey Mark IV differs from the preceding wraps by invaginating the distal esophagus into the fundus, rather than wrapping the fundus transversely about the distal esophagus. Only 270° of the esophagus is wrapped, leaving the posterior wall uncovered [131].

Figure 2.37. Incomplete fundal wrap around esophagus. Film from an upper GI series showing an incomplete fundoplication, perhaps of the Dor type.

Hill advocated attaching portions of the lesser curvature to the median arcuate ligaments of the diaphragm, rather than to the esophagus. Although not strictly speaking a fundoplication, it acts as one, and it is aimed at restoring the normal flap valve anatomy at the gastroesophageal junction [128].

Many variations of these techniques have been introduced. In addition, the traditional open surgical technique is rapidly being supplanted by laparoscopic surgery. All aim at providing symptomatic relief for heartburn and regurgitation. However, if the fundoplication is too tight, either dysphagia or "gas bloat" syndrome may occur.

Figure 2.38. Tight fundoplication. Long narrowing of the distal esophagus due to an overly tight fundoplication.

Dysphagia is the most common symptom and is seen in 30 to 40% of patients in the immediate postoperative period. Over time this decreases to 5% of patients. Some of the dysphagia is initially due to perioperative edema. If persistent, esophageal narrowing may be secondary to a wrap that is too tight. An upper GI series performed with barium may help to identify the narrowing in symptomatic patients (Fig. 2.38). However, the use of a barium tablet (12.5 mm diameter) aids in the diagnosis of significant lesions, especially in patients who experience dysphagia only for solid foods (Figs. 2.39 and 2.40). When encountered, narrowings can be successfully dilated. Less than 1% of patients end up requiring reoperation [132].

Incest Sodozza
Figure 2.39. Tight wrap with entrapped barium tablet. Upper GI series (A) demonstrates a dilated esophagus with a short, smooth, symmetrical narrowing secondary to a tight wrap. Use of a barium tablet reveals obstruction to a swallowed solid (B). The tablet dissolved a few minutes afterward.

"Gas bloat" syndrome, the inability to eructate, causes abdominal discomfort [128,132]. For reasons that remain unclear, it occurs less frequently following laparoscopic surgery [133]. Some authors comparing partial and Nissen fundoplications have reported no significant difference in esophageal motility [134]. Others, however, have reported better overall motility in patients with partial fundoplications [135].

Fundoplication Upper
Figure 2.40. Whirled appearance in a tight fundoplication. Double-contrast upper GI series (A) reveals the whirled appearance of the fundus following fundoplication. A second film from this exam (B) shows the obstructed barium tablet in a deformed fundus.

Some deformity of the stomach may be observed in patients who have undergone a fundoplication. There may be a mass indentation at the level of the fundus where the esophagus enters the stomach (Fig. 2.41), or the submerged portion of the esophagus may be narrowed as it passes through the wrap itself (Fig. 2.42). Sometimes, especially on

Figure 2.41. Fundoplication defect. A deformed fundus with a large filling defect is noted following fundoplication.

Figure 2.42. Fundoplication defect. The submerged segment of the esophagus is narrowed as it passes through a plication defect.

double-contrast examinations, the soft tissues of the wrap may surround the enwrapped esophagus (Figs. 2.43 and 2.44). On CT scans, the fundal gastric mucosa has a whirled appearance as it wraps around the esophagus (Fig. 2.45).

Figure 2.43. Fundal mass secondary to wrap. Figure 2.44. Fundal mass secondary to wrap.

Double-contrast esophagogram reveals part of a Excellent demonstration of a fundal wrap fundoplication as a soft tissue mass about the with its soft tissues surrounding the distal intragastric portion of the esophagus. esophagus.

Figure 2.43. Fundal mass secondary to wrap. Figure 2.44. Fundal mass secondary to wrap.

Double-contrast esophagogram reveals part of a Excellent demonstration of a fundal wrap fundoplication as a soft tissue mass about the with its soft tissues surrounding the distal intragastric portion of the esophagus. esophagus.

Figure 2.45. Whirled CT appearance of fundoplication. Three CT sections demonstrating the whirled appearance of a fundoplication from the level of the gastroesophageal junction (A) to the fundus (B) to the proximal body of the stomach (C).

Figure 2.45. Whirled CT appearance of fundoplication. Three CT sections demonstrating the whirled appearance of a fundoplication from the level of the gastroesophageal junction (A) to the fundus (B) to the proximal body of the stomach (C).

Level Junction

Four different patterns of fundoplication failure have been described [131]. In type I, the fundal wrap becomes undone and the hiatal hernia recurs, with the stomach slipping back into the chest (Figs. 2.46 and 2.47). In type II, the wrap is maintained and remains infradiaphrag-matic in location. However, part of the stomach reenters the chest. The diaphragm pinches the herniated stomach, causing an "hourglass"

Figure 2.47. Type I failed fundoplication. Film from an upper GI series showing a type I failure with undoing of the plication and herniation of the stomach above the diaphragm.

Figure 2.48. Type II failed fundoplication. Schematic diagram of a type II failed fundoplication.

deformity (Figs. 2.48 and 2.49). In type III, part of the stomach lies above the fundal wrap but still is infradiaphragmatic in location. This also gives rise to an "hourglass" deformity (Figs. 2.50-2.52). This is the so-called slipped Nissen repair. In a type IV failure, the wrap remains intact, but the distal esophagus and its wrap herniate through the esophageal hiatus into the chest (Fig. 2.53).

Figure 2.49. Type II failed fundoplication. Film from an upper GI series showing a type II failure with an intact wrap below the diaphragm, but her-niation of the stomach into the chest.

Figure 2.50. Type III failed fundoplication. Schematic diagram of a type III failed fundoplication.

Nissen Fundoplication DiagramNissen Fundoplication Diagram

Figure 2.51. Type III failed fundoplication. Figure 2 52. Type 111 failed fundoplication.

Single-contrast upper GI series showing a small D^b^rontrast upper GI series showing a large portion of stomach proximal to the fundoplication portion of the sto^h pro^^ to the plication defect, but still infradiaphragmatic in location. defect, but below the diaphragm.

Figure 2.51. Type III failed fundoplication. Figure 2 52. Type 111 failed fundoplication.

Single-contrast upper GI series showing a small D^b^rontrast upper GI series showing a large portion of stomach proximal to the fundoplication portion of the sto^h pro^^ to the plication defect, but still infradiaphragmatic in location. defect, but below the diaphragm.

Figure 2.54. Gastroesophageal reflux following Figure 2.55. Peptic stricture following fundo-

failed fundoplication. Upper GI series demon- plication. Upper GI series showing a short peptic strating a type II failure, with marked gastro- stricture in a patient with a prior fundoplication. esophageal reflux.

Figure 2.54. Gastroesophageal reflux following Figure 2.55. Peptic stricture following fundo-

failed fundoplication. Upper GI series demon- plication. Upper GI series showing a short peptic strating a type II failure, with marked gastro- stricture in a patient with a prior fundoplication. esophageal reflux.

When reflux symptoms recur postoperatively, they are usually less intense than before the surgery [132]. Up to 8% of patients are symptomatic 10 years after open surgery. It is expected that laparoscopic surgery will yield similar long-term results. Medical therapy is usually sufficient to control the symptoms as long as the fundoplication is intact. Leaks may occur that are silent clinically. These are often due to improper (too deep) placement of a suture plicating the fundus to the esophagus. These small leaks may be observed and treated expectantly [70]. When reflux is severe (Fig. 2.54), the patient is subject to the development of reflux esophagitis, peptic stricture formation (Figs. 2.55 and 2.56), Barrett's metaplasia, and even carcinoma formation (Fig. 2.57).

Stricture Upper Series
Figure 2.56. Peptic stricture following failed fundoplication. Upper GI series demonstrating an annular peptic stricture in a patient whose fundoplication has become almost completely undone.

Figure 2.57. Failed fundoplication with Barrett's carcinoma. Single-contrast esophagram of a patient with a type IV failure. Note the irregular narrowing of the midesophagus from an adenocarcinoma.

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