ACUTE COMPLICATIONS of ANTI-REFLUX SURGERY Right Ventricle.23 Management of These Problems Is Beyond the Scope of This Chapter

6 Acute Complications of Anti-Reﬂux Surgery Gianmattia del Genio and Jean-Marie Collard

In the last three decades, surgical procedures scopic anti-reflux procedures demonstrate an for gastroesophageal reflux disease showed operative mortality of 0.5%12 and a morbidity significant improvements in outcomes mainly ranging from 4 to 7.3%.13,14 A nationwide analy- because of standardization of the indications, sis comprehensive of all the serious complica- widespread use of accepted fundoplication tech- tions was conducted in Finland between 1987 niques, and improved perioperative manage- and 1996, showing a prevalence of 0.8% of life- ment. Despite the good results of the currently threatening complications including 0.1% of adopted operations,1 acute complications of fatal events.15 Even though a substantial number anti-reflux procedures occur and may be life- of surgical failures do not lead to remedial threatening. Large series with careful long-term surgery, another method to estimate the inci- follow-up are available and demonstrate recog- dence of postoperative complications is to con- nizable patterns of failure.2–6 Complications are sider the reoperation rate. According to Carlson different in type and frequency in relation to and Frantzides,16 the overall reoperation rate both techniques (e.g., partial vs total fundopli- reported in the literature for all the primary cation) and approach (e.g., thoracotomy vs anti-reflux laparoscopic procedures published laparotomy). Recently, the evolution toward the between 1993 and 2000 was 2.8%. use of the laparoscopic approach7–9 changed the In laparoscopic anti-reflux surgery there is a frequency of these untoward events. Some of the direct correlation between the surgeon’s complications traditionally associated with experience and the complication rate17 with the open surgery decreased in incidence (e.g., inci- highest complication rate occurring during the sional hernia, splenic injury), whereas other first five cases and declining to a more accept- specific complications (e.g., intraabdominal able level beyond the twentieth procedure.18 The hemorrhage, herniation of the wrap into the important role of tutorship is demonstrated by chest, perforation of the esophagus or stomach, the lower complication rate and shorter opera- pneumothorax, or pneumomediastinum) occur tive time during the learning curve of late more frequently after laparoscopic surgery.10,11 starters than in the initial experience of Because of the high number of anti-reflux pioneers.18 procedures performed each year and the lack of This chapter addresses the main acute com- any worldwide registry, the exact incidence of plications of anti-reflux surgery irrespective of acute complications is difficult to estimate. the approach (laparotomy vs laparoscopy vs Follow-up studies report a large statistical vari- thoracotomy) and their timing of occurrence ation influenced by the relatively small numbers (intraoperative vs postoperative).It provides the of operations performed in each individual reader with relevant information, guidelines, institution. Retrospective surveys of laparo- and insights that have evolved from study of the

67 68

MANAGING FAILED ANTI-REFLUX THERAPY surgical literature and from the senior author’s perienced laparoscopists should have the con- personal experience. ventional instrumentation opened on a table located in the operating theater,ready to be used at any time. Achieving hemostasis laparoscopi- Intraoperative Complications cally can be a challenging task for the most experienced surgeon even if advanced tech- Vascular Injury nologies are readily available (bipolar cautery, ultrasound, argon beam). The use of smooth Because of the close spatial relationship forceps grasping the damaged vessel is recom- between the hiatal area and the major vascular mended, but injury to either the aorta or infe- structures in the upper abdomen, vascular rior vena cava requires immediate conversion to injuries to major vessels (aorta, vena cava, left laparotomy. The use of a high-flow insufflator hepatic artery, short gastric vessels) may occur helps to maintain a high intraabdominal pres- during anti-reflux surgery (Table 6.1). Use of an sure while suctioning intraperitoneal blood. open approach allows the surgeon to put his Placement of hemostatic clips on the left hepatic index finger right on the damaged vessel for or splenic arteries must not totally occlude the immediate control of the bleeding and, subse- vessels because of the potential risk of hepatic quently, for easy vascular repair with either a or splenic ischemia and necrosis. ligature of the vessel (left hepatic artery, short In open surgery, injury to the spleen is the gastric vessels) or a suture of the vascular wall most frequent cause of intraoperative bleeding, (aorta, vena cava). In contrast, with the laparo- and is usually related to excessive traction on scopic approach, immediate control is much the greater omentum or stomach. This can more difficult to achieve. For this reason, inex- necessitate urgent splenectomy if hemostasis cannot be achieved. The incidence of this event Table 6.1. Intraoperative complications and predisposing has been reduced by the use of minimally inva- factors. sive surgical techniques. In large series of open Vascular injury anti-reflux procedures the reported splenec- Direct injury to the aorta, inferior vena cava, left tomy rate ranged from 1 to 3%,2,19,20 whereas hepatic artery, short gastric vessels, spleen, right both the overall incidence of splenic injury and ventricle splenectomy rate calculated from >6000 laparo- Crushing of the liver with the hepatic retractor scopic anti-reflux procedures was 0.24 and Esophageal and gastric tear 0.06%, respectively.16 Although these data come Inaccurate periesophageal dissection from specialized centers with high caseload Excessive cautery volumes,21 splenectomy has not been reported Inadvertent puncture in many laparoscopic series exceeding 100 Undue traction patients.1 More gentle maneuvers together with Blind maneuver (laparoscopy) Intraluminal bougie the magnification of the image in laparoscopic surgery probably account for the reduced risk of Vagal injury perioperative hemorrhage compared with Posterior esophageal dissection conventional surgery.22 Removal of the fat pad Another cause of intraoperative bleeding Direct injury to either vagal trunk Dense adhesions (reoperative surgery, during laparoscopic fundoplication is inadver- panesophagitis) tent laceration of the liver because of excessive Complete division of the lesser omentum pressure exerted by the hepatic retractor on the liver. The small hepatic fracture that is bleeding Pneumomediastinum (laparoscopy) is usually secured with a compression plug. In Extended transhiatal mobilization of the esophagus High intraabdominal insufflation pressure case of failure of this technique, a variety of other hemostatic options are available, includ- Pneumothorax (laparoscopy) ing argon or bipolar coagulation, biological Inadvertent injury to the pleura glue, or collagen-based hemostatic mesh. Overly Panesophagitis strong use of the liver retractor may cause Esophageal shortening Large hiatal hernia myocardial contusion, and cardiac tamponade has been reported caused by laceration of the 69

ACUTE COMPLICATIONS OF ANTI-REFLUX SURGERY right ventricle.23 Management of these problems is beyond the scope of this chapter. Esophageal and Gastric Tear Esophageal perforation during open anti-reflux surgery is very uncommon.20 Use of a safe method of esophageal dissection helps ensure this low rate of perforation: encircling of the esophagus is performed with the surgeon’s index finger passed smoothly from left to right, the fingertip touching the left crus of the diaphragm, the anterior aspect of the aorta, and the right crus successively, rather than the posterior aspect of the esophageal wall itself. In contrast, because of the loss of tactile percep- tion, intraoperative perforation during laparoscopic anti-reflux procedures is more common and may involve either the distal esophagus or gastric fundus.24 Excessive cautery, inadvertent puncture, undue traction, and incorrect identification of the anatomic planes are the most common mechanisms involved.25,26 Poste- rior esophageal perforation attributed to blind dissection of the lower esophagus flush with its outer muscular layer has been reported by several authors.10,24,27 Perforation of the esophagus or stomach represents the third most fre- Figure 6.1. Short esophagus with the gastroesophageal junc- quent intraoperative complication of anti-reflux tion (white arrow) far away from the diaphragmatic level (black surgery, occurring in 0.78% of cases.16 Similar to arrow). other complications, the risk of perforation follows a learning curve. Schauer et al.24 demonstrated that most perforations occur early (first anesthetist must be done in perfect coordina- 10 cases) during the course of a surgeon’s expe- tion with those by the surgeon. This is especially rience with fundoplication. important with the laparoscopic technique An adequate approach to the hiatal area because the surgeon is unable to palpate the gas- includes starting the dissection just above the troesophageal junction as the bougie is being hepatic branches of the left vagus nerve within passed. In addition, during laparoscopy no trac- the lesser omentum on the right crus of the tion can be exerted on the lower esophagus diaphragm, which must be clearly identified. when the distal tip of the bougie is thought to Further dissection around the lower esophagus have reached the cardia. through the mediastinum must be done under Another process involved in some of the careful visual control. The use of a 30° telescope reported perforations is the presence of a during laparoscopic surgery may be helpful.Con- bougie in the lower esophagus during ditions predisposing to intraoperative esopha- esophageal dissection.28 Under these circum- geal injury include failure to preoperatively stances, the bougie puts the esophageal wall diagnose a short esophagus (Figure 6.1), dense under tension so as to make it more rigid. Most adhesions in relation to severe periesophagitis, surgeons agree that it is best to insert the cali- and previous hiatal surgery. bration bougie just before suturing the fundic Another mechanism involved in intraopera- wrap after the lower esophagus has been tive perforation is the passage of a large- isolated from its crural attachments.29 diameter bougie across the gastroesophageal The worst problem is failure of recognition junction. To do this safely, any maneuvers by the of the tear at the time of the operation. This 70

MANAGING FAILED ANTI-REFLUX THERAPY is especially possible for both posterior esophageal and gastric tears. Any doubtful surgical maneuver requires careful checking of the esophagogastric junction. Either methylene blue injected through the channel of the nasogastric tube lying across the esophagogastric junction or intraoperative upper gastrointestinal endoscopy with transillumination and insufﬂation are useful adjuncts for detecting even very small transmural tears.30,31 When a perforation is discovered intraoperatively, primary repair of the tear in two layers with interrupted stitches is simple and rarely Figure 6.2. Antral manometry tracings showing very low- amplitude contractions after vagotomy (upper tracing, black results in postoperative complications.Coverage arrows) and high-amplitude contractions after erythromycin of the suture line with the fundoplication may therapy has been started (lower tracing, white arrows). help to reinforce the repair.

within the lesser omentum (unnecessary Vagal Nerve Injury surgical maneuver) Circumferential dissection of the lower esopha- We know that truncal vagotomy disturbs the gus exposes the patient to the risk of inadver- functioning of all the organs of the digestive tent injury to one or both vagus nerves. system. It impairs fundic relaxation, antral Anatomic landmarks for recognition of the propulsive activity, pyloric relaxation, gallblad- vagal nerves are the anterior aspect of the der contractility, and possibly results in diar- esophageal wall for the left (anterior) trunk and rhea, dumping or gastric stasis, early satiety, the internal aspect of the right crus for the right increased antral exposure to duodenal contents, (posterior) one. These landmarks are particu- and even cholelithiasis.33–38 Should vagal injury larly relevant in laparoscopy, an approach that occur, erythromycin therapy (motilin-receptor precludes blunt encircling of the esophagus agonist39) should be started as early as possible with the index finger. In some patients, early to enhance the spontaneous motor recovery decussation of the left trunk results in the pres- process that takes place in the myenteric plexus ence of several thin fibers that spread over the of the gastric wall over time40 (Figure 6.2).Doing anterior aspect of the esophageal wall. Circum- so is likely to minimize the unfortunate side stances leading to vagal injury are: effects of the nerve injury for patients who anticipate improvement in quality of life and • Posterior dissection between the posterior digestive comfort by means of an otherwise esophageal wall and the right vagus nerve straightforward functional operation. to pass the fundus in between when con- structing the wrap (optional surgical step)19 Pneumomediastinum • Anterior dissection including the removal and Pneumothorax of a large fat pad across the cardia • Incorporation of the left trunk in the An unusual occurrence in conventional open suture when anchoring the wrap to the fundoplication surgery, both pneumomedi- anterior aspect of the esophageal wall astinum and pneumothorax are new complications that may occur when the anti-reflux • Direct injury to either vagal trunk with the procedure is performed laparoscopically. Pneu- needle when suturing the wrap momediastinum may result from extended • Dense periesophageal adhesions in repeat transhiatal mobilization of the esophagus in operations, as reported by Skinner and combination with a high intraabdominal Belsey three decades ago32 insufflation pressure. It is recognized by subcu- • Division of both the left hepatic artery and taneous emphysema that usually develops in the the hepatic branches of the left vagus nerve neck. Lowering the insufflation pressure during 71

ACUTE COMPLICATIONS OF ANTI-REFLUX SURGERY the procedure may prevent progression of the ognized during the operative procedure (Table pneumomediastinum. In most cases, no specific 6.2). Reports suggest that such an unfortunate treatment is needed; the pneumomediastinum outcome is more likely to occur with the laparo- spontaneously resolves by absorption of the gas scopic approach than after a conventional within a few hours after the operation.41 anti-reflux operation by laparotomy or thoraco- Pneumothorax may develop in relation to tomy.13,24 Although laparoscopy has been either direct opening of either pleural cavity or favored because it provides the surgeon with a diffusion of CO2 through intact pleura. Factors better view of the operative field, it may also predisposing to pneumothorax are: necessitate blind maneuvers, such as those needed for the creation of a large retroe- • Periesophagitis with dense adhesions be- sophageal window or by the insertion of the first tween the esophageal or fundic wall and trocar into the abdomen. Inappropriate use of the pleura the coagulating system also may expose the • Inadvertent injury to the pleura caused by upper gastrointestinal tract to the risk of heat technically inadequate lower mediastinal injury.42 Another cause of postoperative fistula dissection is leakage of an esophageal or gastric suture • Extended mediastinal dissection in the used for repair of an upper gastrointestinal tear presence of esophageal shortening or in that was recognized intraoperatively. In the patients with a large type III (parae- same way, excessive tightening of the knots sophageal) hiatal hernia when anchoring the wrap to the lower esopha- Intraoperative pneumothorax must be recognized as early as possible to avoid the development of gas-exchange disturbances. Table 6.2. Postoperative complications and predisposing Intraoperative closure of the pleural defect may factors. help stop CO2 diffusion into the pleural cavity. The most critical maneuver to be done if the Gastric and esophageal fistula patient becomes unstable because of a tension Unrecognized intraoperative tear (blind dissection) Heat injury to the gastric or esophageal wall pneumothorax is placement of a large-bore Postoperative leakage from erosion of an needle or intravenous catheter in the pleural esophageal or gastric suture cavity through the anterior aspect of the chest Excessive tightening of the knots when anchoring wall. This allows intrathoracic CO2 to escape the wrap to the esophagus from the chest cavity with subsequent reexpan- Excessive tension on the anchoring sites of an sion of the lung parenchyma.Formal evacuation intrathoracic fundoplication to the diaphragm of gas from the pleural cavity must be done at Bleeding the end of the procedure after release of the Rebleeding from any intraoperative vascular repair pneumoperitoneum. Incomplete pleural evacu- Injury to the intercostal artery (thoracic approach) ation or recurrence of pneumothorax on a chest Injury to the epigastric artery (laparoscopic X-ray taken in the recovery room suggests that approach) the lung parenchyma itself has been injured and Slippage of a clip placed on a short gastric vessel requires pleural drainage with a conventional Herniation of the wrap into the chest chest tube until a parenchymal seal is achieved. Sudden increase in intraabdominal pressure (tumultuous recovery from anesthesia, prostatism, constipation, straining under heavy loads) Inappropriate approximation of the crura Acute Postoperative Large hiatal hernia Short esophagus Complications Postoperative gastric distension Gastric and Esophageal Fistula Acute dysphagia Periesophageal dissection A fistula may develop from either the esophagus Too tight a crural closure or stomach in the early postoperative course Too long or too tight a wrap Excessive scarring of the hiatal sling and is usually related to a transmural injury to Unrecognized esophageal body dysmotility the esophageal or gastric wall that was not rec- 72

MANAGING FAILED ANTI-REFLUX THERAPY

• The nasogastric tube is removed only when bowel activity resumes. Perforations confined to the immediate vicin- ity of the digestive wall may be treated con- servatively with antibiotics, acid-suppressing medications, evacuation of gastric contents at regular intervals through the nasogastric tube, and total parenteral nutrition.48 In contrast, noncontained leaks require immediate revision by laparoscopy, laparotomy, or thoracotomy.48 Laparoscopy must be converted into laparotomy whenever proper repair of the defect cannot be achieved through the minimally invasive approach. Figure 6.3. Gastric perforation (black arrow) after laparotomic Late recognition of an esophageal or gastric Nissen fundoplication, in relation to too tight a gastroesopha- leak may lead to life-threatening peritonitis gogastric suture. which could necessitate a procedure as radical as esophagectomy or gastrectomy.49 Mediastini- tis with pleural effusion also may develop from an esophageal injury,50 especially after extended transhiatal dissection of the esophagus to reduce the gastrointestinal junction below the gus may create local ischemia leading to early diaphragm. In such an instance, thoracotomy postoperative perforation (Figure 6.3). If clini- must be considered if the abdominal approach cal symptoms such as fever, excessive abdomi- to the lower esophagus precludes proper sutur- nal pain, or abdominal tenderness develop, a ing of the parietal defect and effective mediasti- contrast swallow using a water-soluble medium nal drainage. must be performed urgently. These complex surgical situations emphasize Twenty years ago, use of an intrathoracic the fact that anti-reflux surgery must be per- Nissen fundoplication for management of short formed by surgeons experienced with both esophagus came into disrepute because of abdominal and thoracic surgical procedures. reports of gastric perforation at the anchoring sites of the wrap to the crura.43–45 Because it is the only anti-reflux procedure that encircles Bleeding the distal segment of a short esophagus, we modified Nissen’s initial technique46 in an Bleeding in the immediate postoperative period attempt to lower the risk of early postoperative is a rare event that must be suspected in the perforation45,47: presence of acute hypotension,tachycardia,con- traction of the urinary output, or shock. The • The hiatus, already enlarged by the pres- absence of intraabdominal drainage may cause ence of the sliding hernia, is widened a delay in diagnosis and necessitate an urgent, further by division of the left crus or per- rather than semielective, reoperation. Bleeding formance of a 3-cm diaphragmatic inci- may come from an intraoperative vascular sion radially from the anterior margin of repair, any splenic or hepatic injury that the crural sling. rebleeds after hemostasis has apparently been • The wrap is made as floppy as possible achieved, or from the incision itself, possibly using a rather large amount of gastric involving an intercostal artery or vein after tissue. thoracotomy or the epigastric artery caused by • To anchor the wrap to the crural sling, the trocar placement for laparoscopy. Watson and surgeon pushes the left part of the colleagues51 reported on a patient who under- diaphragm down with his left hand, went a laparotomy 6 hours after the initial mimicking diaphragmatic contractions that laparoscopic anti-reflux operation for bleeding arise on cough, before placing the sutures. caused by slippage of a clip placed on a short 73

ACUTE COMPLICATIONS OF ANTI-REFLUX SURGERY gastric vessel. To prevent such a complication, it further herniation of the stomach or is wise to apply two hemostatic clips on both herniation of the splenic flexure of the sides of the presumed division point of a vessel. colon alongside the fundoplication into the This is especially important because such clips chest.47 can be dislodged while passing the fundus • After discharge home, manual workers through the retroesophageal window to wrap should be advised against carrying heavy the lower esophagus. loads; similarly, patients with prostatism or constipation should be warned not to Herniation of the Wrap into strain too much when they urinate or have a bowel movement. Each of these condi- the Chest tions increases intraabdominal pressure Herniation of the fundic wrap into the chest excessively and can predispose to break- may occur in the early postoperative period, down of a repair and wrap herniation. even as early as while the patient awakens from • Herniation of the fundoplication into the the anesthetic.Various conditions predispose to chest is more common with the laparo- this unfortunate outcome: scopic approach than after conventional surgery.10 Possible reasons for this are • The physiologic intraabdominal pressure excessive cautery of the peritoneal sheet is higher than the one existing in the covering the crura and misestimation of thorax so that abdominal organs are natu- the amount of tissue incorporated in bites rally attracted to the chest through any when approximating the crura with the defect in the diaphragm, the roof of the laparoscopic technique.52 abdominal cavity. • A sudden increase in abdominal pressure, Total disruption of the crural closure with as may occur when the patient strains herniation of the wrap into the chest may while awakening from anesthesia, may remain totally asymptomatic. Sometimes the push the freshly constructed wrap through fundoplication has sufficient room in the hiatus the hiatus, with subsequent breakdown of and has become fixed in the lower mediastinum, the crural closure. creating a situation similar to what is achieved when an intrathoracic fundoplication is con- • The absence of any crural closure gives structed around a short esophagus.46 To be even better access to the lower medi- effective in controlling gastroesophageal reflux, astinum, especially in patients operated on a total fundoplication does not necessarily have for gastroesophageal reflux disease with a to be located below the diaphragm; rather, our hiatal hernia and in whom the fundic wrap own experience of intrathoracic Nissen fundo- has not been anchored to the hiatal sling. plications when performed for true esophageal • Postoperative distension, which may occur shortening indicates that an intrathoracic wrap if a nasogastric tube has not been placed, is at least as effective as an intraabdominal one, may put the hiatal repair under stress and with a long-term pH-controlled success rate of account, in part at least, for the acute dis- 97%.48 ruption of the crural sutures. Partial disruption of the crural closure, • In the presence of esophageal shortening, together with the absence of spontaneous undue traction on the esophageal tube to fixation of the herniated wrap to the lower construct the wrap below the diaphragm mediastinal tissue, may result in gastric com- also predisposes to early herniation into pression at the diaphragmatic level. This can the chest, which reflects the spontaneous lead to dysphagia, chest pain, dyspnea, and tendency of the short esophagus to go cardiac dysrhythmia, symptoms that require back to its natural location in the lower reoperation to reposition the fundoplication mediastinum. below the diaphragm. Usually, herniation of the • In those patients operated on for a short wrap into the chest is not the only anatomic esophagus, inappropriate anchoring of abnormality found at reoperation.37,53 The wrap an intrathoracic Nissen fundoplication45 is often found to have been partially disrupted, to the crural sling predisposes to either sometimes the wrap no longer exists, or the 74

MANAGING FAILED ANTI-REFLUX THERAPY wrap may have slipped onto the gastric body. • A 2-month convalescence period for Patients with these anatomic problems experi- manual workers ence recurrence of heartburn, which requires • Appropriate management of prostatism take down of the residual wrap followed by the and constipation during the early postop- construction of a proper one around the lower erative period esophagus below the diaphragm. • True esophageal shortening on preopera- Acute transhiatal herniation of the wrap tive barium swallow series must be oper- through a relatively narrow hiatal sling may ated on via thoracotomy45,46 result in strangulation of the hernia with gastric necrosis (Figure 6.4). This life-threatening complication requires an emergency operation and may require resection of the fundus or even Acute Dysphagia esophagogastrectomy whenever the gastric wall cannot be sutured after the removal of the Almost all patients experience some degree of necrotic area. dysphagia after fundoplication surgery. This Techniques for preventing herniation of an transient side effect of the procedure usually intraabdominal fundoplication into the chest resolves within a few weeks postoperatively. include the following: Transient dysphagia is likely a result of physiologic inflammation that develops in the hiatal • Proper approximation of the diaphrag- region after any dissection of the distal esopha- matic crura with incorporation of their gus and gastroesophageal junction, as was sturdy peritoneal sheet in the suture demonstrated in the 1980s after proximal • Anchoring of the wrap to both diaphrag- gastric vagotomy without fundoplication for matic crura with nonabsorbable sutures duodenal ulcer disease.54,55 In contrast, severe • Smooth recovery from anesthesia, pre- dysphagia is suggestive of the crural closure venting the patient from excessive being too tight, a wrap that is too long or too coughing tight, unrecognized esophageal body dysmotil- • Placement of a nasogastric tube during the ity, or excessive scarring of the hiatal sling. The first 12 hours after the operation latter situation was described by Watson et al.56 at the beginning of the laparoscopic era in relation to poor hiatal dissection with excessive use of electric coagulation. Acute incarceration of a freshly constructed wrap in the hiatus also may account for the sudden onset of dysphagia postoperatively. The role of the absence of division of the short gastric vessels in the genesis of esophageal dysphagia is still debated, despite the publica- tion of randomized studies57–59 that fail to show any significant difference depending on whether the vessels are severed or not. However, large series of remedial operations60–62 indicate that, in almost all patients who required a reoperative procedure for persistent dysphagia, their short gastric vessels were left intact at the time of the first operation. The symptom of dysphagia is best assessed by dynamic radiological examination of the esophageal anatomy. An increased diameter of the esophageal tube on barium swallow suggests Figure 6.4. Acute herniation and diaphragmatic strangulation that, sooner or later, remedial surgery will need (black arrow) of the greater curvature after laparoscopic Nissen to be considered (Figure 6.5). However, normal fundoplication in relation to postoperative vomiting. passage of the liquid medium through the 75

ACUTE COMPLICATIONS OF ANTI-REFLUX SURGERY

Figure 6.6. A, Conventional barium swallow study in a patient with excessive scarring of the crural sling after laparoscopic Nissen fundoplication, showing a good passage of the medium through the cardia without any enlargement of the esophageal body.B, Marshmallow study in the same patient, showing stasis of the ingested material in the lower esophagus.

Postoperative complications may consist of intraabdominal or intrathoracic bleeding, Figure 6.5. Conventional barium swallow study, showing a gastric or esophageal fistula, herniation of the dilatation of the esophageal body secondary to excessive fundoplication into the chest, and acute dys- scarring of the crural sling after laparoscopic Nissen phagia. Experience with both primary and fundoplication. remedial anti-reflux operations together with a good knowledge of the mechanisms that underly these acute complications are the key factors for their prevention and management. cardia with no esophageal dilatation does not exclude an underlying organic problem. Indeed, esophageal stasis in some of these patients References may only be revealed by barium-impregnated marshmallow ingestion (Figure 6.6). 1. Catarci M, Gentileschi P, Papi C, et al. Evidence-based appraisal of anti-reflux fundoplication. Ann Surg 2004; 239:325–337. Summary 2. Donahue PE, Samelson S, Nyhus LM, et al. The floppy Nissen fundoplication. Effective long-term control of pathologic reflux. Arch Surg 1985;120:663–668. Acute complications of anti-reflux surgery may 3. Lundell L, Abrahamsson H, Ruth M, et al. Long-term occur during or after the operation. Intraopera- results of a prospective randomized comparison of total tive complications include injury to the upper fundic wrap (Nissen-Rossetti) or semifundoplication abdominal vessels, tear of the esophageal or (Toupet) for gastro-oesophageal reflux. Br J Surg 1996; 83:830–835. gastric wall, injury to the vagus nerves, pneu- 4. Bammer T, Hinder RA, Klaus A, et al. Five- to eight-year mothorax, and pneumomediastinum (laparo- outcome of the first laparoscopic Nissen fundoplica- scopic approach). tions. J Gastrointest Surg 2001;5:42–48. 76

MANAGING FAILED ANTI-REFLUX THERAPY

5. Sandbu R, Khamis H, Gustavsson S, et al. Long-term 24. Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms results of anti-reflux surgery indicate the need for a ran- of gastric and esophageal perforations during laparo- domized clinical trial. Br J Surg 2002;89:225–230. scopic Nissen fundoplication. Ann Surg 1996;223: 6. Hunter JG, Smith CD, Branum GD, et al. Laparoscopic 43–52. fundoplication failures: patterns of failure and response 25. Ellis FH. Editorial comment on: Mullen JT, Burke EK, to fundoplication revision. Ann Surg 1999;230:595–604; Diamond AB. Esophagogastric fistula: a complication of discussion 604–606. combined operations for esophageal disease. Arch Surg 7. Detailed diagnoses and procedures, National Hospital 1975;110:826–828. Discharge Survey. www.cdc.gov/nchs. 26. Gott JP, Polk HC Jr. Repeat operation for failure of 8. Sandbu R, Haglund U, Arvidsson D, et al. Anti-reflux anti-reflux procedures. Surg Clin North Am 1991;71: surgery in Sweden, 1987–1997: a decade of change. 13–32. Scand J Gastroenterol 2000;35:345–348. 27. Cadiere GB, Himpens J, Bruyns J. How to avoid 9. Laparoscopic anti-reflux surgery for gastroesophageal esophageal perforation while performing laparoscopic reflux disease (GERD). Results of a consensus develop- dissection of the hiatus. Surg Endosc 1995;9:450– ment conference. Surg Endosc 1997;11:413–426. 452. 10. Watson DI, Jamieson GG. Anti-reflux surgery in the 28. Horgan S, Pellegrini CA. Surgical treatment of gastroe- laparoscopic era. Br J Surg 1998;85:1173–1184. sophageal reflux disease. Surg Clin North Am 1997;77: 11. Soper NJ, Dunnegan D. Anatomic fundoplication failure 1063–1082. after laparoscopic anti-reflux surgery. Ann Surg 1999; 29. Lowham AS, Filipi CJ, Hinder RA, et al. Mechanisms 229:669–677. and avoidance of esophageal perforation by anesthesia 12. Finlayson SR, Laycock WS, Birkmeyer JD. National personnel during laparoscopic foregut surgery. Surg trends in utilization and outcomes of anti-reflux Endosc 1996;10:979–982. surgery. Surg Endosc 2003;17:864–867. 30. Del Genio A, Izzo G, Maffettone V. The surgical treat- 13. Collet D, Cadiere GB. Conversions and complications ment of gastroesophageal reflux (GER). Minerva Chir of laparoscopic treatment of gastroesophageal reflux 1992;47:571–577. disease. Formation for the Development of Laparo- 31. Chang L, Oelschlager B, Barreca M, et al. Improving scopic Surgery for Gastroesophageal Reflux Disease accuracy in identifying the gastroesophageal junction Group. Am J Surg 1995;169:622–626. during laparoscopic anti-reflux surgery. Surg Endosc 14. Zaninotto G, Molena D, Ancona E. A prospective multi- 2003;17:390–393. center study on laparoscopic treatment of gastroe- 32. Skinner DB, Belsey RHR. Surgical management of sophageal reflux disease in Italy: type of surgery, esophageal reflux and hiatus hernia: long term results conversions, complications, and early results. Study with 1030 patients. J Thorac Cardiovasc Surg 1967;53: Group for the Laparoscopic Treatment of Gastroe- 33–54. sophageal Reflux Disease of the Italian Society of 33. Stadaas JO. Intragastric pressure/volume relationship Endoscopic Surgery (SICE). Surg Endosc 2000;14: before and after proximal gastric vagotomy. Scand J 282–288. Gastroenterol 1975;10:129–134. 15. Rantanen TK, Salo JA, Sipponen JT.Fatal and life-threat- 34. Bremner CG. Gastric ulceration after a fundoplication ening complications in anti-reflux surgery: analysis of operation for gastroesophageal reflux. Surg Gynecol 5502 operations. Br J Surg 1999;86:1573–1577. Obstet 1979;148:62–64. 16. Carlson MA, Frantzides CT. Complications and results 35. Ihasz M, Griffith CA. Gallstones after vagotomy. Am J of primary minimally invasive anti-reflux procedures: a Surg 1981;141:48–50. review of 10,735 reported cases. J Am Coll Surg 2001; 36. Baxter JN, Grime JS, Critchley M, et al. Relationship 193:428–439. between gastric emptying of a solid meal and emptying 17. Bowrey DJ, Peters JH. Laparoscopic esophageal surgery. of the gall bladder before and after vagotomy. Gut 1987; Surg Clin North Am 2000;80:1213–1242. 28:855–863. 18. Watson DI, Baigrie RJ, Jamieson GG. A learning curve 37. Collard JM, Verstraete L, Otte JB, et al. Clinical, radio- for laparoscopic fundoplication. Definable, avoidable, or logical and functional results of remedial anti-reflux a waste of time? Ann Surg 1996;224:198–203. operations. Int Surg 1993;78:298–306. 19. DeMeester TR, Bonavina L, Albertucci M. Nissen fun- 38. Gutschow CA, Collard JM, Romagnoli R, et al. Bile doplication for gastro-esophageal reflux disease: evalu- exposure of the denervated stomach as an ation of primary repair in 100 consecutive patients.Ann esophageal substitute. Ann Thorac Surg 2001;71: Surg 1986;204:9–20. 1786–1791. 20. Urschel JD. Complications of anti-reflux surgery. Am J 39. Annese V,Janssens J, Vantrappen G, et al. Erythromycin Surg 1993;166:68–70. accelerates gastric emptying by inducing antral con- 21. Black N, Johnston A. Volume and outcome in hospital tractions and improved gastroduodenal coordination. care: evidence, explanations, and implications. Health Gastroenterology 1992;102:823–828. Serv Manage Res 1990;3:108–114. 40. Collard JM, Romagnoli R, Otte JB, et al. Erythromycin 22. Hinder RA, Filipi CJ, Wetscher G, et al. Laparoscopic enhances early postoperative contractility of the dener- Nissen fundoplication is an effective treatment for vated whole stomach as an esophageal substitute. Ann gastroesophageal reflux disease. Ann Surg 1994;220: Surg 1999;229:337–343. 472–483. 41. Clements RH, Reddy S, Holzman MD, et al. Incidence 23. Farlo J, Thawgathurai D, Mikhail M, et al. Cardiac tam- and significance of pneumomediastinum after laparo- ponade during laparoscopic Nissen fundoplication. Eur scopic esophageal surgery. Surg Endosc 2000;14: J Anaesthesiol 1998;15:246–247. 553–555. 77

ACUTE COMPLICATIONS OF ANTI-REFLUX SURGERY

42. Testas P.The danger of and correct procedure in laparo- plication: radiologic evaluation. AJR Am J Roentgenol scopic electrosurgery. In: Steichen FM, Welter R, eds. 2002;178:859–862. Minimally Invasive Surgery and New Technology. St. 53. Collard JM, Verstraete L, Romagnoli R. What are the Louis: Quality Medical Publishing; 1994:102–104. consequences of herniation of the repair into the chest? 43. Mansour KA, Burton HG, Miller JI Jr, et al. Complica- Why are they different from the primary intra-thoracic tions of intrathoracic Nissen fundoplication. Ann Nissen? In: Giuli R, Galmiche JP, Jamieson GG, Scarpig- Thorac Surg 1981;32:173–178. nato C, eds. The Esophagogastric Junction. Paris: John 44. Richardson JD, Larson GM, Polk HC Jr. Intrathoracic Libbey Eurotext; 1998:796–798. fundoplication for shortened esophagus. Treacherous 54. Skellenger ME, Jordan PH Jr. Complications of vago- solution to a challenging problem. Am J Surg 1982;143: tomy and pyloroplasty. Surg Clin North Am 1983;63: 29–35. 1167–1180. 45. Collard JM, De Koninck XJ, Otte JB, et al. Intrathoracic 55. Guelrud M, Zambrano-Rincones V, Simon C, et al. Dys- Nissen fundoplication: long-term clinical and pH- phagia and lower esophageal sphincter abnormalities monitoring evaluation. Ann Thorac Surg 1991;51:34–38. after proximal gastric vagotomy. Am J Surg 1985;149: 46. Nissen R, Rossetti M. Die Behandlung Von Hiatush- 232–235. ernien und Refluxösophagitis Mit Gastropexie und 56. Watson DI, Jamieson GG, Mitchell PC, et al. Stenosis of Fundoplicatio. Indikation, Technik und Ergebnisse. the esophageal hiatus following laparoscopic fundopli- Stuttgard: Georg Thieme Verlag; 1959:30–50. cation. Arch Surg 1995;130:1014–1016. 47. Gutschow C, Romagnoli R, Collard JM. What are the 57. Luostarinen ME, Isolauri JO. Randomized trial to study indications for an intra-thoracic Nissen fundoplication? the effect of fundic mobilization on long-term results of What are the drawbacks of this technique? In: Giuli R, Nissen fundoplication. Br J Surg 1999;86:614–618. Siewert JR, Couturier D, Scarpignato C, eds. Barrett’s 58. Blomqvist A, Dalenback J, Hagedorn C, et al. Impact of Esophagus. Paris: John Libbey Eurotext; 2003:498–506. complete gastric fundus mobilization on outcome after 48. Michel L, Collard JM. Surgical management of the laparoscopic total fundoplication. J Gastrointest Surg Mallory-Weiss syndrome and oesophageal perforations. 2000;4:493–500. In: Morris PJ, Malt RA, eds. Oxford Textbook of Surgery. 59. O’Boyle CJ, Watson DI, Jamieson GG, et al. Division of Oxford, UK: Oxford University Press; 1994:868–873. short gastric vessels at laparoscopic Nissen fundoplica- 49. Bladergroen MR, Lowe JE, Postlethwait RW. Diagnosis tion: a prospective double-blind randomized trial with and recommended management of esophageal perfora- 5-year follow-up. Ann Surg 2002;235:165–170. tion and rupture. Ann Thorac Surg 1986;42:235–239. 60. Collard JM, Romagnoli R, Kestens PJ. Reoperations for 50. DeMeester TR. Perforation of the esophagus. Ann unsatisfactory outcome after laparoscopic anti-reflux Thorac Surg 1986;42:231–232. surgery. Dis Esophagus 1996;9:56–62. 51. Watson DI, Pike GK, Baigrie RJ, et al. Prospective 61. Dallemagne B, Weerts JM, Jehaes C, et al. Causes of fail- double-blind randomized trial of laparoscopic Nissen ures of laparoscopic anti-reflux operations. Surg Endosc fundoplication with division and without division of 1996;10:305–310. short gastric vessels. Ann Surg 1997;226:642–652. 62. Hunter JG, Swanstrom L, Waring JP. Dysphagia after 52. Hainaux B, Sattari A, Coppens E, et al. Intrathoracic laparoscopic anti-reflux surgery. The impact of opera- migration of the wrap after laparoscopic Nissen fundo- tive technique. Ann Surg 1996;224:51–57.