Esophagus: Fundoplication

Fundoplication – Types

Nissen Fundoplication Procedure

  • Position in Steep Reverse Trendelenburg
  • Mobilize the Esophagus
    • Divide the Gastrohepatic Ligament – Initial Landmark
      • Watch for Replaced Left Hepatic Artery
    • Bluntly Mobilize the Right Crus
      • Preserve the Anterior Vagus Nerve
      • Keep Peritoneal Covering Over the Crura (Stripping Will Weaken the Repair)
    • Bluntly Mobilize Circumferentially Around the Esophagus Until 3-5 cm Are in the Abdomen Without Tension
  • Divide Short Gastrics to Mobilize the Fundus
    • Stay Off Stomach to Prevent Thermal Injury
    • Avoid Injury to Spleen by Tearing the Capsule
  • Approximate Crura
    • Permanent Interrupted Sutures
    • Indications for Mesh Not Well Defined (Never Use Synthetic Mesh – Risk for Erosion)
    • May Require Diaphragmatic Relaxing Incision
  • Wrap Gastric Fundus Posterior 360-Degrees
    • Use Three Interrupted Permanent Stitches
    • Create Wrap Using the Fundus, Not the Gastric Body
    • Wrap Should be 2-3 cm Short & “Floppy” to Minimize Postoperative Side Effects

Partial Fundoplication

  • Approach Mn
    • Dor Fundoplication
      • Anterior 180-Degrees
    • Toupet Fundoplication
      • Posterior 270-Degrees
  • Better if Concurrent Dysmotility
    • Prevents Worsening

Belsey Mark IV Repair

  • Fundoplication Preformed Through a Thoracotomy Mn
  • Anterior 240-Degrees
  • Potential Indications:
    • Hostile Abdomen
    • Short Esophagus – Able to Free More Esophagus
    • Massive Hiatal Hernia
    • Morbid Obesity

Nissen Fundoplication 1

Nissen Port Placement

Fundoplication Types

Fundoplication – Adjuncts

Collis Gastroplasty

  • Single Linear Staple Along Stomach Cardia to Create a 4-5 cm Neo-Esophagus
    • First Insert a 45-48 French Bougie to Maintain Adequate Patency
  • Indication: Unable to Obtain Adequate Intraabdominal Esophagus Length
    • Minimum 3 cm
  • Only Needed in 2-5% of Cases
    • Extended Mediastinal Dissection/Mobilization is Most Often Sufficient for Lengthening
  • Approaches:
    • Open
    • Combined Thoracoscopic-Laparoscopic
      • Linear Stapler Inserted Through the Thorax After Thoracoscopy Used to Confirm No Adhesions/Obstruction
      • Left Generally Preferred
    • Total Laparoscopic
      • Original Description: 25 mm Circular Stapler Fired 3 cm Below the Angle of His to Allow Passage of a Linear Stapler (Rarely Done Now)
      • Wedge-Collis Gastroplasty (Wedge-Fundectomy): Wedge Resection of Fundus Opposed to Single Staple Line

Hill Esophagogastropexy

  • Indication: Antireflux Surgery with Inadequate Fundus Length for Wrap
    • Possibly Due to Prior Gastric Surgery
  • Procedure:
    • Plication of Lesser Curvature Around the Right Side of the Esophagus
    • Esophagogastropexy to the Median Arcuate Ligament
    • Requires Intraoperative Manometry

Collis Gastroplasty

Fundoplication – Complications

Dysphagia

  • Most Self-Resolve in 4-12 Weeks
  • Strongest Predictor of Postoperative Dysphagia: Preoperative Dysphagia
  • Most Common Cause: Postoperative Edema
  • Most Common Cause Requiring Surgery: Wrap Too Tight
  • Tx: Liquid/Soft Diet Until Symptomatic Resolution
    • If Fails: Dilation
    • If Unable to Tolerate Secretions Requires Return to the OR Due to Wrap Being Too Tight

Gas Bloat Syndrome

  • Wrap Causing Inability to Belch Air
    • Causes Bloating and a Buildup of Gas Within the Stomach
  • Cause: Wrap Too Tight
  • Usually Self-Limiting Within a Few Weeks
  • Tx: Lifestyle Modification
    • Avoid Aerophagia, Straws & Carbonated Beverages
    • Possible Medications: Simethicone, Metoclopramide or Erythromycin
    • Options if Fails:
      • Conversion to Partial Wrap
      • Endoscopic Pneumatic Dilation
      • If Diagnosed Gastroparesis: Pyloroplasty, Pyloric Botox Injection or Pneumatic Pyloric Dilation

Recurrent GERD

  • Most Patients with Recurrent Symptoms Do Not Have Documented Reflux on pH Testing
  • Tx: PPI vs Surgical Revision

Wrap Failure

  • Persistent, Recurrent or New-Onset Symptoms
  • Rate: 10-15%
  • Most Occur within 2 Years
  • Categories
    • Transhiatal Fundoplication Herniation – Most Common Cause of Failure (47-61%)
    • Fundoplication Disruption
    • Slipped Fundoplication
    • Tight Wrap/Crural Stenosis
    • Technical Failure: Twisted Wrap or Malpositioned
      • Most Common Technical Failure: Use of Gastric Body Instead of the Fundus for the Wrap

Postop EGD Findings

  • Nissen Fundoplication: Circumferential Transverse Gastric Fold Involving the Cardia
    • Resembles a “U”
    • Creates a Stacked Coil Appearance
  • Partial Fundoplication: Transverse Gastric Fold Partially Involving the Cardia
    • Resembles a Greek Omega (“Ω”)
  • Disrupted Fundoplication: Transverse Gastric Fold Does Not Involve the Shaft of the Endoscope
    • Occasionally Unable to Even See a Transverse Gastric Fold
  • Twisted Fundoplication: Gastric Fold in an Oblique Position
  • Migrated Fundoplication: Fundoplication Migrated Above the Diaphragm into the Thorax
  • Slipped Fundoplication: GEJ > 2 cm Above the Zone of Pressure
  • Paraesophageal Hernia: Intact Fundoplication with Enlarged Hiatus with Herniation

EGD Findings After Fundoplication: A) Normal Nissen, B) Partial Fundoplication, C) Disrupted Fundoplication, D) Twisted Fundoplication, E) Migrated Fundoplication, F) Slipped Fundoplication, G) Paraesophageal Hernia 2

Mnemonics

Fundoplication Variation

  • Dor: Just Shutting the Front Door
  • Toupet: Looks Like Balding Spot Wrapping Around the Back
  • Belsey is Ballsy to Go in Through Chest

References

  1. Gray H. Public Domain.
  2. Martins BC, Souza CS, Ruas JN, Furuya CK, Fylyk SN, Sakai CM, Ide E. ENDOSCOPIC EVALUATION OF POST-FUNDOPLICATION ANATOMY AND CORRELATION WITH SYMPTOMATOLOGY. Arq Bras Cir Dig. 2021 Jan 15;33(3):e1543. (License: CC BY-4.0)