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Fundoplication Complications

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 GE junction (at B ring) will be above diaphragm; intact wrap around proximal stomach (neoesophagus) will be below diaphragm

IMAGING

• Preoperative: Identify “short esophagus,” hiatal hernia, and dysmotility
• Wrap complications

image Tight FDP wrap (fixed narrowing and delayed emptying of esophagus)
image Complete disruption of FDP sutures (recurrent hernia and reflux), partial disruption of FDP sutures (1 or more loose-looking outpouchings of wrap)
image  
image Intact wrap may slide downward over stomach; “hourglass” configuration of stomach
image Intrathoracic migration of wrap upward through hiatus
• Fluid collections in abdomen or mediastinum

image Herniated abdominal fluid, lymph, hematoma, infection ± leak, abscess
• Videofluoroscopic contrast-enhanced esophagram soon after surgery is mandatory

image Provides structural information, anatomical abnormalities
image Wrap complications, leaks, persistence of reflux
• CT for severe abdominal or chest pain, suspected visceral injury, or abscess

DIAGNOSTIC CHECKLIST

• Postoperative fluoroscopic evaluation should be used liberally or even routinely
• CT for suspected leak or bleeding
image
(Left) Graphic shows a Nissen fundoplication (FDP) with the gastric fundus wrapped completely (360°) around the gastroesophageal junction.

image
(Right) Upright spot film from an esophagram performed soon after a Nissen FDP shows an intact wrap image in its expected subdiaphragmatic location as a filling defect within the air-filled fundus. The distal 3 cm of the esophageal lumen is compressed as it passes through the wrap.
image
(Left) A supine film from the same study shows the intact wrap image as a filling defect with the barium pool in the fundus.

image
(Right) Axial NECT shows an intact FDP as a soft tissue density mass image within the gastric fundus. The metallic staple line is evident within the wrap. The mass effect of the wrap tends to decrease with time following surgery.

TERMINOLOGY

Abbreviations

• Fundoplication (FDP)

Definitions

• Complications of antireflux surgery for management of gastroesophageal reflux disease (GERD)
• Nissen FDP: Complete (360°) FDP

image Approach: Laparoscopic or open FDP
image Gastric fundus wrapped 360° around intraabdominal esophagus to create antireflux valve
image Concomitant hiatial hernia is reduced; diaphragmatic esophageal hiatus sutured
• Toupet FDP: Partial (270°) FDP

image Posterior hemivalve created
• Belsey Mark IV repair: Open surgical; 240° FDP wrap around left lateral aspect of distal esophagus

image Fundus sutured to intraabdominal esophagus; acute esophagogastric junction angle (angle of His)
image Can also be performed via minimally invasive techniques

IMAGING

General Features

• “Wrap” complications

image Slipped or misplaced FDP
image FDP disruption or breakdown
image FDP herniation with intrathoracic migration
image Too tight, too loose, or too long FDP
image Herniation of stomach through diaphragmatic hiatus
• “Non-wrap” complications

image Injury to intraabdominal, intrathoracic organs
image Leaks: Intraabdominal, intrathoracic
image Mediastinal collection of gas and fluid (blood, transudate, or pus)
image Fistulas; gastropericardial, gastrobronchial, etc.
image Pneumothorax, pneumonia, pancreatitis, incisional hernia, mesenteric and portal venous thrombosis
• Late complications

image Recurrent paraesophageal herniation
image Distal esophageal stricture

Radiographic Findings

• Fluoroscopy
• Preoperative evaluation is critical to identify

image Presence, type and size of hiatal hernia (HH)
image Irreducible HH or “short esophagus”

– Stomach is pulled taut into chest; does not return to abdomen on upright positioning
– May require Collis gastroplasty (effectively lengthening esophagus by creating a gastric tube)
– Wrap goes around “neoesophagus” in abdomen = Nissen-Collis FDP
image Also evaluate for reflux and esophageal motility

– FDP is relatively contraindicated in patients with severe dysmotility
• Normal postoperative appearance

image Nissen FDP wrap: Well-defined mass in gastric fundus; smooth contour and surface

– Distal esophagus tapers smoothly through center of symmetric compression by wrap
– Tapered segment 2-3 cm long
– Pseudotumoral defect within gastric fundus = wrap

image Defect more pronounced for complete wrap of Nissen than partial wrap of Toupet, Belsey
image Best detected on upright film (wrap outlined by air in fundus), or supine (wrap as filling defect in barium pool)
image Toupet (partial, posterior) FDP

– Barium may fill portions of wrap

image Don’t mistake for leak or dehiscence
image Distal esophagus should still be “squeezed”
image Nissen-Collis procedure

– Gastroesophageal (GE) junction (at B ring) will be above diaphragm
– Intact wrap around proximal stomach (neoesophagus) will be below diaphragm

image Look for gastric folds within neoesophagus
image Belsey Mark IV repair

– Wrap produces smaller defect than Nissen FDP
– 2 distinct angles form as esophagus passes FDP
– Shallow upper angle; where esophagus, fundus, and diaphragm suture together
– Steep lower angle; where stomach pulled upward
• “Wrap” complications

image Tight FDP wrap

– Fixed narrowing of distal esophagus with delayed emptying
– May also see gas distention of stomach (gas bloat syndrome)
– May also be caused by excessive closure of esophageal hiatus of diaphragm
image Complete disruption (dehiscence) of FDP sutures

– Findings may resemble those of normal patient who has had no surgery
– Recurrent hiatal hernia and gastroesophageal reflux
– Gastric outpouching above diaphragm
– Expected mass of FDP wrap and narrowing of distal esophagus are not seen
image Partial disruption of FDP sutures

– Partially intact wrap; does not squeeze distal esophagus
– 1 or more small outpouchings from fundus
image Slipped Nissen

– Intact wrap may slide downward over stomach
– Hourglass configuration of stomach caused by wrap pinching stomach
image Intrathoracic migration of wrap

– Intact FDP wrap herniates partially or entirely through esophageal hiatus of diaphragm
• “Non-wrap” complications

image Leaks, fistula

– Detected by extravasation of oral contrast medium
– Uncommon since neither esophageal nor gastric wall is usually cut

CT Findings

• “Wrap”: Soft tissue density mass surrounding intraabdominal esophagus

image Extending caudally about 3 cm
image Normal postsurgical esophagus is collapsed without gas or fluid distention
• Wrap dehiscence: Circumferential thickening surrounding distal esophagus (due to wrap) is lacking

image May see recurrent HH; reflux of contrast material into esophagus
• Herniation of intact FDP through diaphragmatic hiatus; seen as mediastinal mass on coronal reformatted images
• Retraction injury to adjacent organs

image May result in liver or splenic laceration
image Right ventricular laceration; cardiac tamponade

– Trauma by liver retractor during laparoscopic FDP
image Bleeding and hematoma in gastric wall or in peritoneal spaces adjacent to stomach and duodenum
• Fluid collections in abdomen or mediastinum

image Ascites, disrupted lymphatic drainage, hematoma, infection ± leak, abscess
image Drainage under CT guidance; may obviate reoperation
• Hollow visceral perforation

image Extraluminal contrast, free air in chest or abdomen
• Superior mesenteric vein and portal vein thrombosis

image Rare; ∼ 2 weeks after laparoscopic FDP

Imaging Recommendations

• Best imaging tool

image Videofluoroscopic contrast-enhanced esophagram

– Structural or morphological abnormalities
– “Wrap” complications, leaks, persistence of reflux
image CT for severe abdominal or chest pain, suspected visceral injury, or abscess
• Protocol advice

image Perform initial postoperative esophagram with water-soluble contrast medium
image Film initially in standing oblique positions
image Include supine films to exclude leak or reflux

DIFFERENTIAL DIAGNOSIS

Postoperative Edema

• Early postoperative period; edema of FDP wrap
• Large, smooth fundal mass with smooth, tapered narrowing of intraabdominal esophagus
• Delayed emptying of contrast material
• Edema usually subsides; less compression of esophagus within 1-2 weeks

image Repeat esophagram shows much smaller defect

Plication Defect

• Disruption of diaphragmatic sutures (not FDP sutures)

image Recurrent HH; above intact FDP wrap

Extragastric Complications

• Abdominal abscess
• Retractor injury to spleen, liver, etc.

PATHOLOGY

General Features

• Etiology

image Surgeon inexperience, operative technique
• Indications for antireflux surgery

image Medical treatment ineffective
image Side effects of long-term medications
image Complications of GERD; esophagitis, stricture, recurrent aspiration pneumonia, asthma, etc.
• Surgery also entails repair of large paraesophageal hernias associated with GERD

CLINICAL ISSUES

Presentation

• Tight wrap: Dysphagia; transient in early postoperative period

image Gas bloat syndrome; upper abdominal fullness, inability to belch, early satiety, flatulence
• Nausea, retching, epigastric pain, diarrhea
• Intrathoracic wrap migrations

image 64% of radiologically visualized intrathoracic migrations have no clinical manifestations
• Intrathoracic gastric herniation after FDP is uncommon, but potentially life threatening

image May lead to gastric volvulus, intrathoracic incarceration of stomach, acute gastric perforation
• Too loose or dehisced FDP: Recurrent reflux symptoms
• Leaks: Pain, fever, leukocytosis
• Visceral injury: Pain, falling hematocrit

Demographics

• Epidemiology

image Incidence of complications is increasing as many laparoscopic FDPs are performed indiscriminately

– Intrathoracic migration of wrap: 30% after laparoscopic Nissen FDP, 9% after open procedure

image Varies by experience and skill of surgeon
– Incidence of paraesophageal hernia is higher after laparoscopic than open FDP

Natural History & Prognosis

• Advantages of laparoscopic FDP: Safe, effective, reduced length of hospital stay and recovery time

image Effective even at long-term follow-up; as effective as open procedures with lower morbidity rate
• Laparoscopic Toupet vs. Nissen FDP

image Similar short-term results
image In longer follow-up, no difference in incidence of post-FDP symptoms related to gas-bloat syndrome
image Recurrence of GERD after Nissen: 8% have symptomatic reflux, 4% by objective testing

– After Toupet: Symptomatic GERD (20%), objective (51%)
– Higher prevalence of patient dissatisfaction, resumption of proton pump inhibitor use
image Superiority of total FDP over partial, even in setting of moderate decreases in esophageal motility
• Laparoscopic FDP: 3.5-5% rate of early postoperative complications

image Surgical failure rate requiring reoperation: 2-17%
• Outcome: Good as long as FDP remains intact

image Overall mortality rate: 0.3%
• Antireflux surgery undertaken primarily to improve quality of life by relieving symptoms of GERD

image Small possibility of reflux symptoms becoming worse after FDP operation (1-2% of patients)
image Creation of new symptoms due to side effects of surgery; may adversely impact quality of life

Treatment

• Minimize complications: Increased surgeon experience and training

image Appropriate operative and imaging techniques
image Low threshold for early laparoscopic reexploration, early radiological contrast studies
image 5-10% of time; may need to change to open procedure while laparoscopic surgery in process
• Dilation of esophagus; reoperation to loosen wrap around esophagus if dysphagia or gas bloat persists
• Repeat laparoscopic Nissen can be performed safely after initial laparoscopic approach; low failure rate
• Prevent recurrent hernia after laparoscopic Nissen FDP

image Appropriate closure of crura and anchoring suture between stomach and diaphragm are helpful
image Reinforcement of hiatal crura using prosthetic mesh

DIAGNOSTIC CHECKLIST

Consider

• Preoperative evaluation by fluoroscopy is critical

image Identify presence, type, and size of HH, especially an irreducible HH (short esophagus)
image Identify stricture, Barrett esophagus, esophageal carcinoma
image Identify and grade degree of esophageal dysmotility
• Postoperative fluoroscopic evaluation should be used liberally or even routinely

image CT for suspected leak or bleeding

image
(Left) A semirecumbent film from an esophagram shows an intact but “tight” FDP with persistent dilation of the esophagus and delayed emptying. The undersurface of the wrap is seen as a filling defect image within the gastric fundus.
image
(Right) This upright film shows marked dilation of the esophagus and delayed emptying as signs of a “too tight” Nissen FDP.
image
(Left) Spot film from an esophagram shows intrathoracic migration of an intact Toupet FDP. Contrast fills the portions of the fundus image that constitute the wrap, but the compression of the distal esophagus is maintained.

image
(Right) Spot film from an esophagram shows a slipped and partially dehisced Nissen-Collis FDP. Barium fills the fundic wrap image, which has slipped through the hiatus image. Suture disruption is implied by the loose compression of the neoesophagus. The B ring image marks the esophagogastric junction.
image
(Left) Slip of an intact Toupet FDP is seen as intact compression of the distal esophagus image, but well above the diaphragm image.

image
(Right) A supine film from the same study shows barium filling part of the Toupet wrap image. This should not be mistaken for a perforation. Note the intact gastric folds within the wrap. The Toupet wrap is often used in older patients with poor esophageal motility, as evident in this patient by slow emptying of the esophagus and tertiary contractions.

image
(Left) Spot film from an esophagram shows extravasation of contrast medium image and gas image into the mediastinum, indicating perforation of the esophagus or the wrap.
image
(Right) An axial CT section in the same case shows large collections of gas and fluid in the mediastinum image due to perforation of the Nissen FDP.
image
(Left) This elderly patient recently had repair of a large paraesophageal hernia and FDP. A spot film from an esophagram demonstrates extravasation of contrast medium image into the mediastinum, from the distal esophagus. Very little contrast reaches the stomach.

image
(Right) NECT in the same case shows a large mediastinal fluid collection of near-water attenuation image, and residual herniation of the stomach image. The dense collection of extraluminal contrast image indicates a leak from near the operative site.
image
(Left) This elderly woman had chest pain and fever following FDP. A spot film from an esophagram shows extravasation of contrast into the mediastinum image and left pleural space image, indicating a leak from the distal esophagus. Very little contrast enters the stomach.

image
(Right) Axial NECT shows a left chest tube image that drained a loculated left hydropneumothorax (not shown here), left lower lobe pneumonia, and extravasated gas and contrast within the mediastinum image.

image
(Left) This elderly man had a falling hematocrit following surgical repair of a large paraesophageal hernia. Axial NECT shows a large mediastinal hematoma image in the space formerly occupied by the herniated stomach. Hemothorax is also evident image.
image
(Right) In the same patient, metallic anchors image are present from the mesh repair of the large hernia, and more mediastinal hematoma is seen image. This hematoma should not be mistaken for leak of contrast medium.
image
(Left) This 67-year-old man had FDP performed by an inexperienced surgeon. A splenic laceration occurred during surgery leading to splenectomy. A postoperative CT shows gas and fluid in the splenectomy bed image.

image
(Right) A more caudal CT section shows a loculated collection of gas and fluid image, subsequently confirmed to be due to a leak from the operative site. A small liver laceration image is also seen.
image
(Left) A more caudal CT section shows more of the extravasated gas and fluid image from the FDP site.

image
(Right) A sagittal reformatted image from the CT scan shows the left subphrenic collection of extravasated gas and fluid image near the site of the FDP.
image
Axial CECT shows intact gastric fundus with oral contrast medium surrounding the FDP wrap.

image
Axial CECT shows distal esophagus surrounded by extravasated contrast medium within the mediastinum due to perforation of the esophageal wall.

SELECTED REFERENCES

1. Schijven, MP, et al. Laparoscopic surgery for gastro-esophageal acid reflux disease. Best Pract Res Clin Gastroenterol. 2014; 28(1):97–109.

2. Jobe, BA, et al. Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel. J Am Coll Surg. 2013; 217(4):586–597.

3. LeBedis, CA, et al. The diagnostic and therapeutic role of imaging in postoperative complications of esophageal surgery. Semin Ultrasound CT MR. 2013; 34(4):288–298.

 

Epstein, D, et al. Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease: cost effectiveness study. BMJ. 2009; 339:b2576.

Furga, P, et al. [The outcomes of treatment of gastroesophageal reflux disease with laparoscopic “floppy” fundoplication.]. Pol Merkur Lekarski. 2009; 26(155):395–398.

Hamdy, E, et al. Response of atypical symptoms of GERD to antireflux surgery. Hepatogastroenterology. 2009; 56(90):403–406.

Baker, ME, et al. Gastroesophageal reflux disease: integrating the barium esophagram before and after antireflux surgery. Radiology. 2007; 243(2):329–339.

Graziano, K, et al. Recurrence after laparoscopic and open Nissen fundoplication: a comparison of the mechanisms of failure. Surg Endosc. 2003; 17(5):704–707.

Fernando, HC, et al. Outcomes of laparoscopic Toupet compared to laparoscopic Nissen fundoplication. Surg Endosc. 2002; 16(6):905–908.

Hainaux, B, et al. Intrathoracic migration of the wrap after laparoscopic Nissen fundoplication: radiologic evaluation. AJR Am J Roentgenol. 2002; 178(4):859–862.

Pavlidis, TE. Laparoscopic Nissen fundoplication. Minerva Chir. 2001; 56(4):421–426.

Waring, JP. Postfundoplication complications. Prevention and management. Gastroenterol Clin North Am. 1999; 28(4):1007–1019. [viii-ix].

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