Brant K. Oelschlager, MD University of Washington Treating Complications Dysphagia, Leaks, Gastric Dysfunction Following Nissen Fundoplication Brant K. Oelschlager, MD University of Washington

Key to Treating Foregut Complications Prevention

Dysphagia Early versus Late

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

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

Dysphagia Incidence Causes 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 Esophageal dysmotility

Work-up UGI Endoscopy Preferably by you Manometry 24-pH Monitoring

Treatment will be based on the cause Causes of Dysphagia Recurrent Hiatal Hernia Too Tight Incorrect Orientation Motility No apparent etiology - Rare Treatment will be based on the cause

The Gastroesophageal Junction and the Wrap are Above the Diaphragm Type IA Hernia The Gastroesophageal Junction and the Wrap are Above the Diaphragm GERD Occasionally Dysphagia

Causes of Recurrent Hiatal Hernia Large Hiatal Hernia Poor Closure Short Esophagus Obesity Identify the cause and do something different!

Biologic Mesh Reinforced Repair

Short Esophagus

Short Esophagus Collis Gastroplasty Sandone C. Ann Surg. 2000; 232:630-40

Short Esophagus Wedge Gastroplasty Terry M. Am J Surg 2004; 188:195-99

Short Esophagus - Vagotomy No Vagotomy Vagotomy p-value Symptom (n=72) (n=30) Heartburn 2.1 ± 3.0 1.7 ± 1.3 .652 Regurgitation 1.0 ± 2.2 0.8 ± 1.0 .408 Abdominal Pain 1.7 ± 3.0 1.8 ± 2.8 .749 Dysphagia 1.3 ± 2.4 1.6 ± 2.3 .212 Chest Pain 0.8 ± 1.8 0.6 ± 1.6 .607 Bloating 2.2 ± 3.1 2.7 ± 3.3 .481 Nausea 2.1 ± 3.3 1.5 ± 3.1 .483 Diarrhea 2.3 ± 3.6 3.1 ± 3.7 .129 Early Satiety 2.0 ± 2.9 2.6 ± 3.4 .313 Dumping 25% 33% >1/week 21% 30%

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.

Malpositioning

Fundoplication Too Tight Technique Dilate, but wait if possible

Type II Hernia Paraesophageal Hernia GERD Dysphagia or Both

Type III Hernia Dysphagia Occasionally GERD Malformation of the wrap. The body of the stomach is used to perform the fundoplication. Dysphagia Occasionally GERD

Proper Grasp for Fundoplication

Symmetric Nissen

Symmetrical Repair

Non-Symmetrical Nissen

Motility Disorders – Primary Disorders Swallow Aperistaltic contractions Non-relaxing LES

Motility Disorders Wait, Patience, Wait Dilate Revise to a Partial Fundoplication

Dysphagia and Normal Anatomy & Function Wait Patience Dilate 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 UGI (best test) CT (being used more frequently) 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

Endoscopic Therapy Metallic 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

Bloating/Gastric Dysfunction Now compared to before operation Bloating severity post-op 28 patients (<10%) develop new bloating 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 Initial Treatment Recognition Supportive

Effectiveness of Emptying Procedures with a Nissen 141 patients with DGE symptoms Grp 1 (n=63) – DGE Sxs and DGE Grp 2 (n=78) – DGE Sxs and no DGE Grp 3 (n=418) – No DGE Sxs Grp 1 – 47/63 had pyloroplasty Grp 1 w/o pyloroplasty More bloating, flatulance, and abdominal pain Less diarrhea Khajanchee and Swanstrom. Arch Surg 2009;144:823

Effectiveness of Emptying Procedures with a Nissen Masqusi and Velonovich. World J Surg 2007;31:332

Improvement in Gastric Emptying with Fundoplication 36 patients 10 with Delayed GE 26 Normal GE Improvement in GE after Nissen Equal control of GERD (pH monitoring) Pts with normal GE had increase in post-prandial satiety Bais JE. Ann Surg 2001;234:139

Summary of Preoperative and Postoperative Symptoms* Watson, D. I. et al. Arch Surg 2004;139:1160-1167. Watson, D. I. et al. Arch Surg 2004;139:1160-1167. Copyright restrictions may apply.

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 PEG Emptying Procedure Partial Fundoplication Gastrectomy

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