A fistula may develop from either the esophagus or stomach in the early postoperative course and is usually related to a transmural injury to the esophageal or gastric wall that was not rec ognized during the operative procedure (Table 6.2). Reports suggest that such an unfortunate outcome is more likely to occur with the laparo-scopic approach than after a conventional anti-reflux operation by laparotomy or thoracotomy.13,24 Although laparoscopy has been favored because it provides the surgeon with a better view of the operative field, it may also necessitate blind maneuvers, such as those needed for the creation of a large retroe-sophageal window or by the insertion of the first trocar into the abdomen. Inappropriate use of the coagulating system also may expose the upper gastrointestinal tract to the risk of heat injury.42 Another cause of postoperative fistula is leakage of an esophageal or gastric suture used for repair of an upper gastrointestinal tear that was recognized intraoperatively. In the same way, excessive tightening of the knots when anchoring the wrap to the lower esopha-
Table 6.2. Postoperative complications and predisposing factors.
Gastric and esophageal fistula Unrecognized intraoperative tear (blind dissection) Heat injury to the gastric or esophageal wall Postoperative leakage from erosion of an esophageal or gastric suture Excessive tightening of the knots when anchoring the wrap to the esophagus Excessive tension on the anchoring sites of an intrathoracic fundoplication to the diaphragm
Rebleeding from any intraoperative vascular repair Injury to the intercostal artery (thoracic approach) Injury to the epigastric artery (laparoscopic approach)
Herniation of the wrap into the chest Sudden increase in intraabdominal pressure (tumultuous recovery from anesthesia, prostatism, constipation, straining under heavy loads) Inappropriate approximation of the crura Large hiatal hernia Short esophagus Postoperative gastric distension
MANAGING FAILED ANTI-REFLUX THERAPY
gus may create local ischemia leading to early postoperative perforation (Figure 6.3). If clinical symptoms such as fever, excessive abdominal pain, or abdominal tenderness develop, a contrast swallow using a water-soluble medium must be performed urgently.
Twenty years ago, use of an intrathoracic Nissen fundoplication for management of short esophagus came into disrepute because of reports of gastric perforation at the anchoring sites of the wrap to the crura.43-45 Because it is the only anti-reflux procedure that encircles the distal segment of a short esophagus, we modified Nissen's initial technique46 in an attempt to lower the risk of early postoperative perforation45,47:
• The hiatus, already enlarged by the presence of the sliding hernia, is widened further by division of the left crus or performance of a 3-cm diaphragmatic incision radially from the anterior margin of the crural sling.
• The wrap is made as floppy as possible using a rather large amount of gastric tissue.
• To anchor the wrap to the crural sling, the surgeon pushes the left part of the diaphragm down with his left hand, mimicking diaphragmatic contractions that arise on cough, before placing the sutures.
• The nasogastric tube is removed only when bowel activity resumes.
Perforations confined to the immediate vicinity of the digestive wall may be treated conservatively with antibiotics, acid-suppressing medications, evacuation of gastric contents at regular intervals through the nasogastric tube, and total parenteral nutrition.48 In contrast, noncontained leaks require immediate revision by laparoscopy, laparotomy, or thoracotomy.48 Laparoscopy must be converted into laparo-tomy whenever proper repair of the defect cannot be achieved through the minimally invasive approach.
Late recognition of an esophageal or gastric leak may lead to life-threatening peritonitis which could necessitate a procedure as radical as esophagectomy or gastrectomy.49 Mediastini-tis with pleural effusion also may develop from an esophageal injury,50 especially after extended transhiatal dissection of the esophagus to reduce the gastrointestinal junction below the diaphragm. In such an instance, thoracotomy must be considered if the abdominal approach to the lower esophagus precludes proper suturing of the parietal defect and effective mediasti-nal drainage.
These complex surgical situations emphasize the fact that anti-reflux surgery must be performed by surgeons experienced with both abdominal and thoracic surgical procedures.
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