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Review
. 2018 Aug;113(8):1137-1147.
doi: 10.1038/s41395-018-0115-7. Epub 2018 Jun 14.

Complications of Antireflux Surgery

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Free PMC article
Review

Complications of Antireflux Surgery

Rena Yadlapati et al. Am J Gastroenterol. .
Free PMC article

Abstract

Antireflux surgery anatomically restores the antireflux barrier and is a therapeutic option for proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease or PPI intolerance. Laparoscopic fundoplication is the standard antireflux surgery, though its popularity has declined due to concerns regarding wrap durability and adverse events. As the esophagogastric junction is an anatomically complex and dynamic area subject to mechanical stress, wraps are susceptible to disruption, herniation or slippage. Additionally, recreating an antireflux barrier to balance bidirectional bolus flow is challenging, and wraps may be too tight or too loose. Given these complexities it is not surprising that post-fundoplication symptoms and complications are common. Perioperative mortality rates range from 0.1 to 0.2% and prolonged structural complications occur in up to 30% of cases. Upper gastrointestinal endoscopy with a comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Management hinges on differentiating complications that can be managed with medical and lifestyle optimization versus those that require surgical revision. Reoperation is best reserved for severe structural abnormalities and troublesome symptoms despite medical and endoscopic therapy given its increased morbidity and mortality. Though further data are needed, magnetic sphincter augmentation may be a safer alternative to fundoplication.

Conflict of interest statement

Conflicts of Interest: RY: Consultant for Ironwood; JEP: Consultant for Crospon, Ironwood, Torax, Astra Zeneca, Takeda, Impleo, Medtronic, Sandhill; ESH: Consultant for Baxter, Boston Scientific

Figures

Figure 1.
Figure 1.
Surgical fundoplication techniques. A) A complete 360 degree Nissen fundoplication creates a nipple valve. On retroflexed endoscopic view the lip of the valve should be thin, the body of the valve should have a “stacked coils” appearance in alignment with the long axis of the endoscope, and the valve should adhere tightly to the scope. The posterior groove will be deep and anterior groove will be shallow. White lines depict the appropriate orientation of the gastric folds as just below the diaphragm and directed perpendicular to the endoscope and parallel to the diaphragm. B). The Toupet fundoplication is a partial 270 degree posterior wrap which creates a flap valve. The lip of the valve should be thick and “omega” shaped and the valve should be moderately adherent to the scope. Both the anterior and posterior groove should be shallow. C). The Dor fundoplication is a partial 180 degree anterior wrap which creates a flap valve. The lip of the valve should be wide and “S” shaped, and the valve should be moderately adherent to the scope. The anterior groove should be shallow, and there is no posterior groove. Drawings borrowed from Jobe et al. Endoscopic images courtesy of the Esophageal Center at Northwestern.
Figure 2:
Figure 2:
Endoscopic Views of fundoplication complications associated with disruption. Panel A show that the wrap is disrupted and the folds are more parallel with the endoscope. In Panel B the wrap is partially intact and there is disruption of the crural repair and a paraesophageal hernia tracking along side of the wrap and into the chest. Panel C is a frank recurrence of the hernia with only a hint of the remnant wrap noted deep in the type III hernia. Courtesy of the Esophageal Center at Northwestern
Figure 3.
Figure 3.
Slipped Nissen with frank herniation above the diaphragm and a partially intact wrap below the diaphragm depicted on esophagram (A), high-resolution manometry (B), and Endoscopy (C-front view, D-Retrofelxed view. The red lines show the corresponding anatomic locations. Panel A represents the esophagram showing the herniation and the tight wrap [rotating blue arrow] with an elevated intrabolus pressure between the end of the distal esophagus and the diaphragm. The wrap is located at the white arrow and the obstruction is at the diaphragm (black arrows showing crural contraction). Panels C and D are the endoscopic images. Note the esophagitis in this patient who presented with food impactions and reflux symptoms. Courtesy of the Esophageal Center at Northwestern
Figure 4:
Figure 4:
A fundoplication associated with dysphagia and food impaction. The large white arrow is identifying the esophagogastric junction (EGJ) and location of the wrap. Panel A is a tight fundoplication that appears intact and outside of being slightly long is relatively normal appearing. The esophagram in panel B supports minimal emptying and exhibits a tight EGJ at the diaphragm. Panel C is a high-resolution manometry with high intrabolus pressure compartmentalized between the peristaltic contraction and the wrap and this is associated with a high integrated relaxation pressure of 31.5 mmHg. Panel D represents a new approach using FLIP-panometry that defines EGJ opening dimensions and also provides evidence of motor function by assessing changes in diameter as opposed to pressure. The scale in Panel C is pressure (mmHg) while the scale in Panel D is diameter (mm). Courtesy of the Esophageal Center at Northwestern
Figure 5a.
Figure 5a.
Approach to patient with symptoms after an antireflux procedure with normal anatomy on esophagogastroduodenoscopy (EGD) and/or upper GI (UGI) series -Symptoms may be obstructive: dysphagia, esophageal regurgitation, gas-bloat, chest pain or food impaction -Symptoms may be associated with abnormal reflux: heartburn, chest pain, regurgitation Functional lumen imaging probe (FLIP); Los Angeles (LA); Esophagogastric junction outflow obstruction (EGJOO); Peroral endoscopic myotomy (POEM)
Figure 5b.
Figure 5b.
Approach to patient with symptoms after an antireflux procedure with abnormal anatomy on esophagogastroduodenoscopy (EGD) and/or upper GI (UGI) series -Symptoms may be obstructive: dysphagia, esophageal regurgitation, gas-bloat, chest pain or food impaction -Symptoms may be associated with abnormal reflux: heartburn, chest pain, regurgitation Functional lumen imaging probe (FLIP); Los Angeles (LA)

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