Anatomic fundoplication failure after laparoscopic antireflux surgery

Abstract

Objective: Anatomic fundoplication failure occurs after antireflux surgery and may be more common in the learning curve of laparoscopic antireflux surgery (LARS). The authors' aims were to assess the incidence, presentation, precipitating factors, and management of anatomic fundoplication failures after LARS.

Summary background data: The advent of LARS has increased the frequency with which antireflux surgery is performed for the treatment of gastroesophageal reflux disease. Postoperative symptoms frequently occur and may result from physiologic abnormalities or anatomic failure of the fundoplication (e.g., displacement or disruption). Few data exist on the potential causes or best treatment of anatomic fundoplication failures.

Method: LARS was performed in 290 patients by one of the authors over a 6-year period. In the first 53 patients (group 1), the short gastric vessels were divided on a selective basis and the diaphragmatic crura were closed only when large hiatal hernias were present. In the subsequent 237 patients (group 2), the crura were always approximated posterior to the short gastric vessels and full fundic mobilization was performed. Clinical postoperative evaluation was performed on a regular basis, with detailed tests of anatomy and physiology when untoward symptoms developed. Postoperative foregut symptoms were reported by 26% of the patients, of whom 73% were found to have an intact fundoplication. In 7% of the entire group, anatomic failure of the fundoplication was demonstrated, with the majority exhibiting intrathoracic migration of the wrap with or without disruption of the fundoplication. New-onset postoperative epigastric or substernal chest pain frequently heralded fundoplication failure. Factors correlated with the development of anatomic fundoplication failure included presence in group 1, early postoperative vomiting, other diaphragm "stressors," and large hiatal hernias. Repeat operation has been performed in 8 of the 20 patients (40%), with 5 patients successfully treated using laparoscopic techniques.

Conclusions: Anatomic fundoplication failure occurred in 7% of patients undergoing LARS, with the majority occurring in patients who underwent surgery during the learning curve. Anatomic failure is associated with technical shortcomings, large hiatal hernias, and early postoperative vomiting. Full esophageal mobilization and meticulous closure of the diaphragmatic crura posterior to the esophagus should minimize anatomic functional failure after LARS.

Figure 1. Barium swallow obtained 24 hours after a laparoscopic Nissen fundoplication in a patient who vomited after surgery. The fundoplication has herniated through the diaphragmatic hiatus into the mediastinum (small arrows), and the impression of the diaphragm on the herniated fundus can be clearly seen (heavy arrow).

Figure 2. Barium swallow obtained 6 months after laparoscopic Nissen fundoplication in a patient with mild substernal discomfort. The fundoplication with air and barium within it (small arrow) can be seen protruding alongside the esophagus above the diaphragm (heavy arrows).

Figure 3. This patient vomited within the first 24 hours after a laparoscopic Nissen fundoplication. The wrap can be seen to be partially disrupted and located in the mediastinum (small arrow) above the level of the left hemidiaphragm (heavy arrows).

Figure 4. In this patient, recurrent heartburn and regurgitation developed 1 year after a laparoscopic Toupet fundoplication. A barium swallow revealed partial unwrapping of the fundoplication, with the fundus (small arrow) protruding above the level of the diaphragm (heavy arrows).

Figure 5. This patient had a large (5-cm) hiatal hernia with extensive periesophageal scarring at the time of laparoscopic Nissen fundoplication. After a bout of sneezing 6 months after surgery, dysphagia developed. A barium swallow revealed a recurrent hiatal hernia, with the gastroesophageal junction (small arrow) located well above the diaphragm, and the fundoplication defect can be seen around the proximal stomach (heavy arrow) at the level of the diaphragm.