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

3. Key to Treating Foregut Complications
Prevention

4. Dysphagia
Early
versus
Late

5. 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

6. 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

7. 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

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

9. 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

10. 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

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

12. Biologic Mesh Reinforced Repair

13. Short Esophagus

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

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

16. 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%

17. Obesity & Antireflux Surgery
Normal Overweight Obese
n (%) n (%) n (%)
Recurrence 4 (5%) 7 (8%) 15 (31%)
No Recurrence 85 (95%) 80 (92%) (69%)*†
* P = vs. obese
† p < vs. normal
Perez AR, Surg Endosc 2002;16:1380.

18. Malpositioning

19. Fundoplication Too Tight
Technique
Dilate, but wait if possible

20. Type II Hernia
Paraesophageal Hernia
GERD
Dysphagia
or Both

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

23. Proper Grasp for Fundoplication

24. Symmetric Nissen

25. Symmetrical Repair

26. Non-Symmetrical Nissen

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

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

29. Dysphagia and Normal Anatomy & Function
Wait
Patience
Dilate
Revise to a Partial Fundoplication

30. Management of Esophageal Leaks
Recognition
Diagnosis
Treatment

31. 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

32. 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?

33. Treatment of Post-Surgical Leaks
Small, contained leaks
Antibiotics +/- drain and wait
Leaks occurring and recognized in the first hours
Consider laparoscopic reoperation, primary closure and buttress
Late occurring

34. 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

35. Gastric Dysfunction

36. 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)

37. 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

38. Bloating Avoidance Avoid Vagal trauma (Including nerve of Laterjet)
Pre-operative Counseling
Beware of associated IBS
Initial Treatment
Recognition
Supportive

39. 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

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

41. 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

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

43. 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

44. In light of recent Supreme Court rulings
“Before we consider assisted suicide, Mrs. Jones, let’s give the Prilosec a chance”