The disrupted fundoplication is perhaps easiest to diagnose and repair. The preoperative evaluation of these patients will usually include a 24-hour pH study, esophageal motility testing, barium swallow, and EGD. If the patient has erosive esophagitis on EGD, the pH study may be omitted but it is generally advisable to do a complete physiologic evaluation before reoperating on a patient with a disrupted fundoplication.
Although disrupted fundoplications are well known in the era of open surgery, two new defects were described after the advent of laparoscopic fundoplication. These are the twisted fundoplication and the two-compartment stomach. The twisted fundoplication results when the surgeon fails to mobilize the greater curvature of the stomach from the spleen and diaphragm. This is more frequently the case when the short gastric vessels are not divided. A portion of the anterior wall of the stomach is pulled from the left around the esophagus posteriorly and sutured to another portion of the anterior wall of the stomach which has been pulled from a spot low on the greater curvature. This creates tension at the gastroesophageal junction which can result in a rotation of the distal esophagus and fundopli-cation to develop a spiral-type deformity seen in retroflexion of the endoscope (Figure 7.3). This deformity is usually associated with symptoms of dysphagia and severe postoperative gas bloat. An esophageal dilator will usually pass through this defect easily, but upon removal of the dilator, the twist will be recreated. Thus, esophageal dilation has little role in managing this deformity.
Occasionally, individuals who have a spiral deformity because of inadequate fundus mobilization will develop a second problem, which is that of the two-compartment stomach. This occurs because the point on the greater curvature chosen for the left side of the fundoplica-tion, when pulled through the gastroesophageal junction, will create a waste around the mid-stomach. The fundic compartment resides against the posterior left hemidiaphragm in the distal compartment (the atrium) lies below the septation. The proximal compartment is filled preferentially with food and will create early satiety, upper gastric discomfort, nausea, and retching. The twisted valve relaxes poorly and thus retching does not usually result in relief of the gastric distension. These patients are extremely uncomfortable and require urgent operation once the diagnosis is made. Barium swallow and upper endoscopy usually reveal the septated nature of the stomach, and the diagnosis is not difficult.
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