Potential Causes of Failure

Regardless of the surgical nuances, failed antireflux operations can be analyzed and subdivided into three distinct anatomic regions.

Failure can occur at the esophageal, wrap, or crural level, although there may be overlapping or concurrent issues. Before the wide adoption of laparoscopic techniques,wrap disruption was the most common mode of failure. In the laparoscopic era, the most common cause of failure is herniation of the wrap through the diaphragmatic hiatus.

The construction of a fundoplication (particularly a 360° fundoplication) may unmask previously unrecognized esophageal dysmotility or misdiagnosed achalasia leading to severe postoperative dysphagia. Chronic inflammation can also contribute to esophageal failure. Both Barrett's esophagus and severe esophageal reflux are associated with chronic esophageal inflammation. Chronic inflammation results in fibrosis, foreshortening, esophageal dysmotility, and poor acid clearance. Poor acid clearance in turn contributes to more esophageal irritation and the vicious cycle is propagated. Over time, the esophagus may become significantly foreshortened and fibrotic. Although there is controversy over the true incidence of the short esophagus, we believe that this entity exists.

A variety of issues involving fundoplication construction can contribute to failed anti-reflux surgery (Figure 8.4). The easiest failure to diagnose and repair is the "missin' Nissen"—a fundoplication that is disrupted or completely undone. A "slipped" Nissen results when the body of the stomach intussuscepts through the fundoplication. This creates an hourglass defect with part of the stomach residing above the wrap and part below. Patients with a "slipped" fundoplication often experience severe reflux and regurgitation because the pouch of stomach above the wrap traps food and serves as a reservoir of acid-rich refluxate below an incompetent esophageal sphincter. Similarly, a wrap may be misplaced around the upper stomach rather than around the esophagus. This creates an hourglass defect in which the wrap is below the diaphragmatic hiatus, but the upper stomach and gastroesophageal junction are above the diaphragm. Another common error particularly in the laparoscopic era is use of the body or even antrum of the stomach to construct a Nissen fundoplication (Figure 8.5). This leads to a twisted, bulky wrap that fails to function properly. Lastly, a fundoplication that is too tight may result in dysphagia. Since the work of


Dunnington and DeMeester8 established the efficacy of the floppy fundoplication, most surgeons construct 360° wraps over a 56-60 French dilator to avoid this problem. However, constructing a wrap over a large dilator without adequate fundic mobilization can still lead to tension. By routinely dividing the short gastric vessels and approximating the crura, Soper and Dunnegan1 reported the failure rate of primary laparoscopic fundoplication decreased from 19% to 4%. Whereas others have demonstrated that division of the short gastric vessels does not improve the clinical outcome of laparoscopic fundoplication, the Nissen procedure performed in this study as the control was not the classic "floppy" fundoplication with full mobilization.9 As such, we believe that the short gastric vessels should be divided with full mobi-

Floppy Fundoplication
Figure 8.4. Types of surgical failure of Nissen fundoplication. (Reprinted from Hinder RA. Gastroesophageal reflux disease. In: Bell RH Jr, Rikkers LF, Mulholland MW, eds. Digestive Tract Surgery: A Text and Atlas. Philadelphia: Lippincott-Raven Publishers; 1996:19, with permission.)


Nissen Failure

Figure 8.5. The body or antrum of the stomach can be mistakenly used to form the fundoplication. A proper fundoplication is constructed by wrapping "A" around the distal esophagus and bringing "B" anterior to the esophagus to join "A." By bringing "C"anteriorly to complete the wrap,a malformed fundoplication will be created.

Figure 8.5. The body or antrum of the stomach can be mistakenly used to form the fundoplication. A proper fundoplication is constructed by wrapping "A" around the distal esophagus and bringing "B" anterior to the esophagus to join "A." By bringing "C"anteriorly to complete the wrap,a malformed fundoplication will be created.

lization of the fundus in order to create a wrap that lies comfortably around the esophagus.

There are a myriad of partial fundoplications in use today. The most common laparoscopic partial fundoplication is the posterior fundopli-cation described by Andre Toupet. Because few surgeons had experience with this repair in the open era, modern-day laparoscopic surgeons tend to make this fundoplication too short. In contrast to the Nissen fundoplication, longer is better for a Toupet procedure. The wrap should extend for at least 4 cm. Belsey fundoplication failures are usually attributed to inadequate esophageal mobilization or improper depth of suture placement when constructing the wrap.

The competency of the crural closure is critical in the performance of a successful fundo-plication. The crural closure can either be too tight leading to dysphagia or too lax leading to transdiaphragmatic herniation of the wrap. In open operations, the crural closure should admit the tip of the surgeon's index finger snugly when a nasogastric tube lies in the esophagus. Obviously, this rule of thumb cannot be used for laparoscopic operations. We try to leave 1-1.5 cm of space between the anterior border of the esophagus and the anterior margin of the hiatus to approximate the degree of closure obtained in open operations. Although some use a bougie to calibrate the hiatal closure5 we find this method both inaccurate and dangerous. The quality of the crura and ability to obtain a well-approximated and tension-free closure are essential. Patients with large hiatal hernias at the time of their initial surgery are three times more likely to develop a recurrence.1 Recent publications have demonstrated the feasibility and utility of judiciously placing prosthetic material to buttress the crural closure when the crural fibers are attenuated.10,11

Without a doubt, the best time to prevent recurrence is at the time of the original procedure. Anticipating potential pitfalls and problems at the esophageal, wrap and crural level during the initial procedure will prevent later complications. We recommend esophageal manometry for all patients before anti-reflux surgery and if weak peristalsis is present, a partial, rather than a total fundoplication, should be performed. The esophagus should be adequately mobilized such that 2-3 cm of tension-free intraabdominal esophagus can be obtained. If a foreshortened esophagus is discovered preoperatively or intraoperatively, an esophageal lengthening procedure should be performed. The establishment of a 2- to 4-cm length of intraabdominal esophagus is a fundamental principle of anti-reflux surgery. If tension is required to keep a fundoplication in the abdomen, transdiaphragmatic herniation will ultimately result. The crura should always be closed with a nonabsorbable suture, often reinforced with the use of pledgets.

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