Fundoplication Complications

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 19/07/2015

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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
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