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Intrathoracic fundoplication for shortened esophagus
lntrathoracic Fundoplication for Shortened Esophagus Treacherous Solution to a Challenging Problem
J. David Richardson, MD, Louisville, Kentucky Gerald M. Larson, MD, Louisville, Kentucky Hlram C. Polk, Jr., MD, Louisville, Kentucky
Although some controversy remains as to the procedure of choice for gastroesophageal reflux, the Nissen fundoplication has provided effective reflux control in the overwhelming majority of patients reported in the literature [I]. We prefer a transahdominal approach for routine primary repair while the transthoracic route has been reserved for complex cases such as reoperation, the possibility of carcinoma and stricture with acquired shortening of the esophagus. The shortened and often stretched esophagus represents a difficult situation, in that even with thorough esophageal mobilization to the aortic arch, the fundoplication wrap occasionally cannot be reduced below the diaphragm. In this eventuality the surgeon may elect to leave the wrap in a supradiaphragmatic position or perform an esophageal lengthening procedure using the Collis gastroplasty combined with a fundoplication [2,3]. Although anecdotal comments of favorable results or catastrophes had been made on the supradiaphragmatic fundoplication, there were no organized reports on such patients before 1980. Two patient series have now been reported in which the fundoplication was left above the diaphragm. Disastrous results were reported in one group [4]; in the other series the supradiaphragmatic fundoplication was found to be a safe, effective method of managing the difficult problem of stricture with a shortened esophagus [5]. Our experience with supradiaphragmatic fundoplication, which we initially were pleased with, has been fraught with hazard when viewed from the perspective of a longer follow-up with more pa-
From the Department of Surgery, University of LouisvilleSchool of Medicine, Louisville. Kentucky. Requests for reprints should be addressed to J. David Richardson, MD, Department of Surgery, University of Louisville School of Medicine, 530 South Jackson Street, Louisville, Kentucky 40202. Presented at the 22nd Annual Meeting of the Society for Surgery of the Alimentary Tract, New York, New York, May 19-20, 1981.
Volume 143,
January 1982
tients. This report outlines our experience with what we now feel is a treacherous solution to a challenging problem and argues strongly against its continued use. Clinical
Material
We performed over 600 fundoplications for recalcitrant esophagitis, including dilatable strictures. More than three fourths of the primary operations that were performed for conditions other than stricture were carried out through a transabdominal approach. Patients with stricture and an acquired shortening of the esophagus had operative. correction through a left thoracotomy with intraoperative dilatation of the esophagus and use of a Nissen fundoplication. The operative features of this procedure and results obtained with its use were published previously [6,7]. Over the last 6 years, we encountered 15 patients in whom we could not reduce the fundoplication below the diaphragm after completion of the fundic wrap. Three of these patients were treated with a Collis gastroplasty to “lengthen” the esophagus with a subsequent total fundoplication. Twelve patients had the fundoplication left above the diaphragm. When a wrap could not he reduced below the diaphragm, the hiatus was surgically widened so that it would not act as a point of constriction on the intrathoracic portion of the stomach. The crura were then sutured to the wrap itself to prevent herniation of other viscera into the chest. A conscious point in each procedure was avoidance of diaphragmatic constriction. All patients have been followed up to date (range 16 months to 6 years, mean 3.5 years). Results The 12 patients with a supradiaphragmatic fundoplication all had prompt relief of esophagi& symptoms and control of gastroesophageal reflux. Two patients required repetitive postoperative dilatation but are now asymptomatic and do not need continued dilatation. However, 5 of the 12 patients have had major complications after creation of the intrathoracic fundoplication. In one patient, colonic 29
Richardson et al
TABLEI
Clinical Features of Patients With Gastric Ulcer
History and Indication for Operation 65 year old woman with long dilatable stricture at 30 cm 52 year old man with esophageal stricture at 32 cm; had two previous repairs
74 year old man with esophagitis and stricture at 35 cm; previous vagotomy and pyloroplasty and crural repair 53 year old woman with stricture; one previous operation
Postoperative Interval to Diagnosis
Location of Ulcer
6mo
Lesser curvature at hiatus
12 mo
Lesser curvature above hiatus
2mo
Fundic wrap eroded into bronchus with gastrobronchial fistula
18mo
Posterior wall of stomach in chest above hiatus
paraesophageal hernia developed through the widened hiatus. Chest pain and fear of strangulation prompted reoperation with reduction of the colon to the abdomen and crural repair. The intrathoracic segment remained in the chest and the patient is asymptomatic 2 years later. Four patients developed ulcerations within the intrathoracic stomach, diagnosed 2, 6, 12 and 18 months postoperatively (Table I). Two of the ulcers were located at the hiatus on the lesser curvature, one ulcer was on the posterior wall above the hiatus, and one was in the superior portion of the fundic wrap. The ulcers were diagnosed by flexible endoscopy in three patients and by barium studies in one patient. Medical management was attempted in three patients. One patient now has a healed ulcer although it recurred on one occasion after cessation of therapy. Another had a persistent gastric ulcer that failed to respond to antacids and cimetidine, but the patient has refused further operative treatment. A third patient who did not respond to medical treatment with antacids and cimetidine had a subsequent operation with performance of Collis gastroplasty and repeated fundoplication after the initial wrap was dismantled. This patient is asymptomatic 2 years after her last operation. One patient had erosion of an ulcer in the superior portion of the fundic wrap into the left lower lobe bronchus, with a gastrobronchial fistula causing severe bilateral pneumonia. Despite division of the fistula and resection of the damaged lung, the patient died from unrelenting pulmonary sepsis. An investigation of gastric emptying was undertaken in the three patients who did not have life-
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Possible Cause Delayed gastric emptying on technetium scan Difficult dissection. Possible vagal injury. Upper gastrointestinal normal emptying stomach Previous vagotomy. No obstruction on barium upper gastrointestinal study. Clearance study not done Gastric emptying normal on technetium study
Treatment
Outcome
Antacids, cimetidine, metoclopramide Antacids, cimetidine
Reoperation: left thoracotomy, division of fistula, left lower lobectomy, gastroplasty Initial medical treatment with antacids, cimetidine required. Reoperation with Collis gastroplasty
Persistent gastric ulcer until metoclopramide started. Now healed. Ulcer healed and recurred. Now healed. Asymptomatic
Died, pulmonary sepsis after reoperation
Asymptomatic 2 years postoperatively
threatening complications. Two patients had technetium-99m sulfur-colloid labeled chicken liver scans to measure the solid phase of the gastric emptying. One patient had delayed gastric emptying that improved with metoclopramide, while another patient had normal gastric emptying. A third patient had only a barium study of gastric emptying. In our series of over 600 patients with Nissen fundoplication we have had 10 recurrences of hiatal hernias. Three of these 10 patients have had gastric ulceration within the herniated segment. Only two of our patients without a recurrence of hiatal hernia have had gastric ulcer. Case Reports 1. A 65 year old woman had severe dysphagia for 8 months and a 4 year history of mild dysphagia. A midCase
esophageal stricture was present on barium swallow and the fiberoptic endoscope would not advance beyond a stricture at 30 cm. Brushings and biopsy of the stricture were negative for carcinoma. A left thoracotomy was performed and a benign stricture was found, which was dilatable to size 46 French. A fundoplication was performed over the dilator, but the shortened esophagus precluded abdominal placement of the wrap. The fundoplication was left in the chest. The patient had marked early improvement and was discharged on a regular diet without dysphagia. She required dilatation on three subsequent occasions. Six months after the operation she had upper gastrointestinal hemorrhage. An upper gastrointestinal series showed a large gastric ulcer on the lesser curvature at the level of the hiatus (Figure l), which was substantiated by flexible endoscopy (Figure 2). Antacids and cimetidine were employed for several months with improvement in symptoms, but the ulcer did not completely heal. Subsequently, technetium sulfur-colloid scan showed
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lntrathoracic Fundoplication
Figure 2. Endoscopk vlew of the lntrathorack gastrk segment, which was prompted by upper gastrolntestlnsl hemorrhage and disclosed a large, deep ulcer at the level of the hlatus (arrows).
F@aw 7. Barium study demonstrates dllatatkn of the upper porikn of ths stomach ( white anvws) de@e careful attempts to prevent constrktkn at the diaphragm. A large ulcer is present at the level of the hiatus (black arrow).
delayed gastric emptying that improved with metoclopramide (Figure 3). The ulcer has now completely healed, documented by endoscopy and barium studies, although she continues to require occasional esophageal dilatations. Comment: There was good evidence to support the diagnosis of delayed gastric emptying in this patient. Whether or not inadvertent injury to the vagus nerve was the casue of this phenomenon is unknown, but the favorable response to metoclopramide and the healing of a long-standing gastric ulcer suggested that vagotomy was potentially responsible. Case 2. A 74 year old man with a long history of severe heartburn was admitted for progressive dysphagia and weight loss. He had undergone vagotomy and pyloroplasty 12 years before to “reduce gastric acidity” and provide symptomatic relief of heartburn. Ten years earlier transthoracic crural repair had been performed. Neither procedure had afforded significant improvement in symptoms. Endoscopy disclosed a stricture at 35 cm with severe ulceration of the esophagus. The stricture was easily dilatable to size 44 French. Transthoracic fundoplication was performed, but the wrap was left in the left hemithorax because of esophageal shortening. The initial postoperative course was smooth, and the patient had relief of heartburn and dysphagia. Two months later he developed acute left chest pain, prompting admission to a coronary care unit. However, electrocardiographic and cardiac enzyme studies were normal and fiberoptic endoscopy was performed. No ulceration of the stomach was detected, and there was near-total healing of the esophagus, which previously had been severely inflamed. Two days after admission, the patient developed fulminant bilateral pneumonia and re-
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quired ventilatory support. An air leak into the gastrointestinal tract prompted radiologic evaluation (Figure 4). A gastrobronchial fistula was present, which filled both the right and left lungs with contrast material through the left lower lobe bronchus. Reoperation was performed and a large gastric ulcer in the superior portion of the fundic wrap was found. The ulcer had eroded into the left lower lobe of the lung with a fistulous communication from the stomach to the lower lobe bronchus. The lower lobe was resected, the ulcer was closed in two layers, the fundoplication was dismantled, and a Collis-Nissen procedure was performed. The patient continued to have bilateral necrotizing pneumonia and died from pulmonary failure.
NORMAL
L.L.
L.L. (metoclopram!de)
Figure 3. Gastrk mot/My. Gastric emptybtg In our patient (L.L.) was slower than in other normal controls, as measured by technetium-99m. Metoclopramlde converted emptying toward the normal range.
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Richardson et al
omy. An upper gastrointestinal series did not demonstrate gross evidence of gastric obstruction, but quantitative studies of gastric emptying were not performed.
Figure 4. Preoperative barium swallow discloses a long strkture with marked proximal dllatatlon of the esophagus. Dlvertkula are present (arrows).
Case 3. A 57 year old man presented with a I5 year history of epigastric and retrosternal burning pain after eating, which had increased in frequency and severity. In addition, he could swallow only liquids. A barium swallow showed an extremely shortened esophagus with a long distal stricture (Figure 5) which could only be dilated to a size 22 French. Transthoracic fundoplication was performed after intraoperative dilatation to a 36 French caliber; however, due to the severe shortening, the fundoplication could not be reduced into an intraabdominal position and was left in the chest. Postoperatively the patient had prompt relief of heartburn and improvement in dysphagia. Dilatation was required twice for the first 2 months after operation and was easily performed to a size 42 French. He required an additional dilatation 10 months postoperatively and is presently asymptomatic and eating a regular diet. A barium swallow 16 months after operation showed an area of persistent narrowing but was greatly improved over the preoperative study (Figure 6). Comment: This case was included for contrast to the two previous case histories because it demonstrates the occasional gratifying result that can be obtained with supradiaphragmatic fundoplication. We feel that close observation of this patient is required to prevent complications if ulceration of the intrathoracic stomach should occur.
Comments Comment:
This lethal complication might have been prevented by immediate recognition of the cause of the chest pain and operative treatment of the ulcer. “Normal” results of endoscopic examination led us to believe that the pain was not due to a postoperative complication. Whether delayed gastric emptying can be implicated is problematic; nonetheless, the patient had previously undergone vagot-
Flgure 5. Preopera tlve barium 8 walk w dlscloses a kng strkture wlth marked proximal dllatatkn af the es@agos. Dlvertkula are present ( arrow ) .
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The results fundoplication complications
achieved with intraabdominal Nissen are excellent [8-101, with few major reported. However, there is relatively
Flgure 6. Postoperative study disclosed some lessening of the strkture and less proximal dllatatlon. 77te patient’s Improvement In symptoms was more dramatk than the radkgraphk Improvement.
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little in the surgical literature to document either the safety or the danger of leaving the fundoplication above the diaphragm in acquired short esophagus. Hollenbeck and Woodward [l I] described 45 combined fundic patch-fundoplication procedures, of which several cases required that the wrap be left in the chest. They reported no complications with this maneuver. At a recent international symposium on esophageal diseases, Woodward [12] stated that he had no complications with the intrathoracic segment of wrapped stomach. Pennell [5] described the “floppy Nissen” fundoplication as an effective means of controlling reflux strictures when the wrap is left in a suprathoracic position, reporting 10 cases in which the patients had a good result without complications. However, he did note that two of the six patients with so-called “conventional or snug Nissen fundoplication” developed ulceration and bleeding when the wrap was left above the diaphragm. Although there have been anecdotal discussions of the hazards of an intrathoracic fundoplication, there are few reports of complications with such an approach. Mansour et al [4] recently described an experience with disastrous complications after supradiaphragmatic placement of a fundoplication. One of four patients in their series with a Thal-Nissen (fundic wrap fundoplication) procedure had intrathoracic rupture of the stomach with a gastrobronchial fistula similar to that reported in our series. Ten additional patients had a fundoplication left in the chest, and 4 had severe complications. One had lesser curvature ulceration requiring gastrectomy, one had a herniation of the wrap producing gastric outlet obstruction, and two had intrathoracic gastric rupture leading to death. Rupture and fistulization from the fundoplication segment have been reported by others [13,14], but these complications have generally followed an abdominally placed fundoplication. Burnett et al [15] reported a much higher complication rate after transthoracic fundoplication, but these problems did not seem to be related to a supradiaphragmatically placed gastric wrap. Henderson (personal communication) treated three referral patients with previously placed interthoracic fundoplications who developed severe complications. One died from gastric perforation and two required urgent operation for correction of hemorrhage. Ulceration of the stomach in a patient previously treated by fundoplication has been reported, even when the wrap was left below the diaphragm. Bushkin et al [16] reported on 5 patients (3.1 percent) with gastric ulcers of the lesser curvature in a series of 160 patients undergoing Nissen fundoplication. This complication was not observed in 200 patients who underwent the Allison or posterior gastropexy method of hiatus hernia repair. Bremner [17] noted four instances of gastric ulceration in 43 patients after the Nissen fundoplication. We have now observed gastric ulceration in only 4 of 600 patients
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treated by Nissen fundoplication if the hiatus hernia did not recur. If, as the available reports suggest, there is a slightly increased incidence of gastric ulceration after abdominal fundoplication, there are several possible mechanisms to explain this phenomenon. Bushkin et al [16] implicated the gas-bloat syndrome and noted that four of their five patients who developed gastric ulcers after a Nissen procedure had coexistence of the two problems. They theorized that the bloating resulted in antral distention with increased gastrin release, although gastrin levels were not measured. Vagal injury with delayed gastric emptying was implicated as the cause of ulceration in the other patient. Twenty-four hour pH studies, which showed alkaline gastric contents, caused Bremner [17] to suggest that bile reflux may be responsible for the 10 percent incidence of gastric ulcers seen after Nissen fundoplication in his series. Finally, careful clinical studies from the laboratory of Little et al [18] showed that gastric emptying is abnormally delayed in unoperated patients with gastroesophageal reflux. This suggests that the somewhat higher incidence of gastric ulceration after fundoplication may be related to gastric stasis rather than to a postoperative abnormality induced by the procedure itself. When the fundoplication is left in the chest there are at least three possible explanations for the observed high incidence of ulceration and perforation: (1) negative intrathoracic pressure which promotes distention of the wrap causing gastrin release as well as delayed emptying and potential ulceration, (2) constriction of the stomach at the hiatus with delayed emptying, and (3) vagal injury with subsequent retarded emptying. The effects of negative intrathoracic pressure on the stomach have not been well studied, but this has not been a particular problem for patients with esophagogastrostomy for carcinoma. However, short survival time and the absence of a 360” wrap may make this analogy invalid. The hypothesis that negative intrathoracic pressure alone contributes to gastric ulceration would explain the fairly high incidence of ulceration we have seen in patients with recurrent hernias and a gastric segment in the chest (three ulcers in 10 recurrences). In our patients with an intrathoracic fundoplication, we went to great lengths to avoid gastric constriction at the hiatus. Therefore, we do not believe hiatal constriction contributed to the observed complications. The possibility of vagal injury is real and must be strongly considered in two of our patients. One had a deliberate vagotomy many years before, and the other had a difficult dissection of the esophagus with demonstrated delayed gastric emptying postoperatively. The superimposition of a vagal injury in a patient who had no pyloroplasty may be sufficient to lead to ulceration. However, we had an additional patient with ulceration who had normal gastric emptying on technetium scan, indi-
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Richardson et al
eating that this mechanism does not provide a satisfactory solution for even our small series of complications. Our experience, combined with the few other published reports, suggest that a fundoplication placed in the chest is not a reasonable alternative for a shortened esophagus due to chronic gastroesophageal reflux. We have been slow to recommend the routine use of the gastroplasty combined with a fundoplication in uncomplicated hiatus hernia cases as has been advocated by some groups, because we have seen in our referral practice several instances of fistula from the staple line and one case of neartotal gastric necrosis after this procedure. However, the inability to reduce effectively the wrap below the diaphragm is a clear-cut indication for gastroplasty followed by fundoplication. Although our experience with this approach is limited, it has been successful, and that, coupled wih the more extensive favorable reports [2,3] suggests that this option is preferable to the treacherous alternative of leaving the wrap above the diaphragm. Summary Intrathoracic fundoplication was used in 12 patients with acquired shortening of the esophagus secondary to gastroesophageal reflux. While several patients had excellent results using this approach, five major complications occurred. One patient developed a paraesophageal hernia, while four had ulceration within the wrap itself. One had serious hemorrhage, while another required reoperation to dismantle the intrathoracic wrap. One patient developed a gastrobronchial fistula and eventually died from pulmonary sepsis. The cause of these problems is unknown, but delayed gastric emptying was implicated in two patients. Even though leaving a Nissen fundoplication in the chest seems to be an attractive alternative when the surgeon cannot reduce the wrap below the diaphragm, this alternative is fraught with treacherous complications in a large percentage of patients. References 1. Ellis FH Jr. Controversies regarding the management of hiatus hernia. Am J Surg 1980;139:782-8. 2. Ellis FH Jr, Leonardi HK, Dabuzhsky L, Crozier RE. Surgery of the short esophagus with stricture. An experimental and clinical manometric study. Ann Surg 1978;188:341-50. 3. Orringer MB, Sloan H. Combined Collis-Nissen reconstruction of the esophogogastric junction. Ann Thorac Surg 1978; 2516-21. 4. Mansour KA, Burton HG, Miller JI Jr, Hatcher CR Jr. Complications of intrathoracic Nissen fundopkation. Ann Thorac Surg 1981;32:173-8. 5. Pennell TC. Supradiaphragmatic correction of esophageal reflux strictures. Ann Surg 1981;193:655-65. 6. Polk HC Jr, Zeppa R. Hiatal hernia and esophagitis: a survey of indication for operation and technic and results of fundoplication. Ann Surg 1971;173:775-81. 7. Polk HC Jr. Fundoplication for reflux esophagitis. Misadventures with the operation of choice. Ann Surg 1976;183:645-52.
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8. DeMeester TR, Johnson LF, Kent AH. Evaluation of current operations for prevention of gastroesophageal reflux. Ann Surg 1974;180:511-5. 9. Dilling EW, Peyton MD, Cannon JP, Kanaly PJ, Elkins RC. Comparison of Nissen fundoplication and Belsey Mark IV in the management of gastroesophageal reflux. Am J Surg 1977;134:730-3. 10. Ellis FH Jr, El-Kuro MF, Gibb SP. The effect of fundoplication on the lower esophageal sphincter. Surg Gynecol Obstet 1976;143:1-5. 11. Hollenbeck JI. Woodward ER. Treatment of peptic esophageal strictures with combined fundic patch fundoplication. Ann Surg 1975;182:472-8. 12. Woodward ER. Surgical treatment of stricture complicating gastroesophageal reflux. In: Stipa S, Belsey RH, eds. Medical and surgical problems of the esophagus. New York: Academic Press, 1981. 13. lkard RW, Jacobs JK. Gastropericardial fistula and pericardial abscess. Unusual complications of subphrenic abscess following Nissen fundoplication. South Med J 1974;67: 17-9. 14. Mullen JT, Burke EL, Diamond AB. Esophagogastric fistula. A complication of combined operations for esophageal disease. Arch Surg 1975; 110:826-8. 15. Burnett HI, Read RC, Morris WD, Campbell GS. Management of complications of fundoplication and Barrett’s esophagus. Surgery 1977;82:521-30. 16. Bushkin FL, Woodward ER, O’Leary JP. Occurrence of gastric ulcer after Nissen fundoplication. Am Surg 1976;42:8216. 17. Bremner CG. Gastric ulcer after the Nissen fundoplication. Surg Gynecol Obstet 1979;148:62-4. 18. Little AG, DeMeester TR, Kirchner PT, O’Sullivan GC, Skinner DB. Pathogenesis of esophagitis in patients with gastroesophageal reflux. Surgery 1980;88:101-7.
Discussion Tom R. DeMeester (Chicago, IL): As Dr. Richardson pointed out, this problem occurs in only about 10 percent of the patients who have an antireflux procedure and only in about one fourth of these patients does the reconstruction need be left in the chest. This occurs for two reasons. First, it is a big step to go from an antireflux reconstruction that cannot be reduced into the abdomen, to a colon interposition, particularly if one’s experience with colon interposition is minimal. Thus, most surgeons are eager to find a simpler solution, Second, we have known for years that a hiatus hernia is a condition in which the stomach is in the chest without any known problem, and therefore, we reason, why not leave a fundus wrap in the chest? But this logic is fallacious for the following reasons: In a hiatus hernia, the phrenoesophageal membrane makes up the hernia sac and serves as an extension of the abdominal cavity into the chest so that the stomach in the hernia sac is actually in the abdomen and under abdominal pressure. When the hernia sac is removed during the construction of a Nissen fundoplication and the reconstruction is left in the chest, a differential pressure develops between the luminal aspect of the stomach and the pleural cavity with only the stomach wall in between. As a consequence of the reconstructed competent cardia and the negative intrapleural and positive intraabdominal pressure, the stomach gradually dilates into the chest. An air-fluid level can occur in the stomach, indicating gastric retention and the potential for the development of an ulcer. As a consequence, a repair left in the chest is subject to all the complications of a paraesophageal hernia: ulceration, strangulation, perforation and bleeding. I am grateful that
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the authors had the courage to report the catastrophies they had in leaving a Nissen fundoplication in the chest. This experience is a lesson that all should remember. Finally, I am not sure whether Collis gastroplasty is the proper way to handle this problem. It is our view that adequate mobilization often will allow the repair to be placed under minimal tension into the abdomen. This may require mobilization above the aortic arch and division of pulmonary branches of the left vagal nerve. If after these maneuvers we are unable to reduce the repair into the abdomen, we prefer to use a short colon interposition. Philip Donahue (Chicago, IL): This report clearly describes some of the problems of the intrathoracic Nissen procedure, and the explanation given is one we would agree with, namely, that the incarcerated segment and poor gastric emptying in the supradiaphragmatic segment lead to stasis and ulceration. We avoid this problem whenever possible at the University of Illinois. When we use the Collis procedure we usually use a modified Collis procedure not dividing the stomach after applying the stapler but merely wrapping the stomach around the esophagus, and we find that satisfactory in most cases. The second group of patients in this presentation are the ones I would like to discuss at some length, namely, those whose intraabdominal wrap migrates into the thorax. This report emphasizes that crural repair with nonabsorbable sutures must precede any attempt at formal fundoplication, usually by the abdominal route, and if it is done by the thoracic route then the crural repair has to be done after fundoplication, after the wrap has been reduced beneath the diaphragm. The question I have for the authors is this: Do you take any special steps to identify patients postoperatively whose wrap has migrated through the hiatus? Do you mark the wrap with small metal clips or do you perform serial roentgenographic examinations to determine which patient’s wrap has migrated through the hiatus? I think the incidence of such asymptomatic migrations is somewhat higher than the less than 5 percent quoted in this study, and perhaps this group of patients should be identified in some way as a high risk group for complications of herniated Nissen fundoplication. Timothy C. Pennell (Winston-Salem, NC): Dr. Polk and his confreres have contributed greatly to our understanding and management of esophageal reflux over the years. Supradiaphragmatic Nissen fundoplication will work, and will work safely when properly done. Our series was 16 patients; only 2 had less than 18 months’ follow-up, and the longest follow-up was 8 years. There are three essentials if one is forced to leave a fundic wrap above the diaphragm. One is that the hiatus must be sufficiently patulous to introduce at least four fingers and preferably the entire fist through the hiatus. The second thing is that the fundoplication must be “floppy.” The hiatal ring must be secured appropriately to the gastric wall as the wall passes through the hiatus. When these principles were followed there were no com-
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Fundoplication
plications. This is not a procedure to be done electively, but I think it can be done before interposition. I congratulate the authors again, particularly on the concept that we must look at other factors related to the cause of complications. Is it more than just obstructive stasis from basically a blind loop obstruction? Paul H. Jordan (Houston, TX): When you bring the stomach through the hiatus, what precautions do you take in order to make the hiatus large enough? I have been under the impression that if you make a radial incision in the diaphragm and tack the diaphragm around the stomach, you don’t have this problem if the opening is sufficiently large. I wonder how large you make this opening. James Maher (Jackson, MS): I would like to say a word or two in defense of the intrathoracic fundoplication. Ed Woodward and I recently looked up the results of our Thal-Nissen procedures. We now have 69 patients with an average follow-up of 5 years. There have been two diaphragmatic hernias but no gastric ulcerations in the intrathoracic stomach. We have, however, seen gastric ulcerations in patients with intraabdominal fundoplication. This is a well-described syndrome, with no apparent predilection for intrathoracic fundoplication. The data on gastric retention were very interesting. We recently had a patient who presented with gastric ulceration after transabdominal fundoplication, in whom we were able to demonstrate gastric retention of solids and postprandial hypergastrinemia with subsequent formation of a “Dragstedt ulcer” from gastric stasis. I would like to ask the authors whether or not the isotopic emptying method they used measured gastric emptying of solids or liquids, since there is a difference between the two that should be addressed. J. David Richardson (closing): Dr. DeMeester, we always mobilize the esophagus completely. We believe that we would not be able to reduce the wrap below the diaphragm otherwise. However, we do find an occasional patient, as we reported today, in whom even with supraaortic mobilization, one simply cannot reduce the fundoplication below the diaphragm. In that setting, inadvertent vagal injury is almost always a possibility. Regarding the question about slippage of the wrap above the hiatus, we note that we do close the crura in all patients. We do not place clips about the fundoplication, but we routinely study all patients at both 6 and 12 months and have not found the problem of the Nissen wrap slipping back into the chest. A question was asked about gastric emptying, which we measure in the solid phase using technetium sulfur colloid. Our operative technique is almost identical to that described by Dr. Pennell, except that we don’t use quite as big a dilator, preferring a size 44 instead of a 56. We open the hiatus to where it is patulous and cannot constrict the stomach. We asked Dr. Woodward to discuss the report because of the apparent discrepancy between his results and ours, and are glad he sent a representative to bring us up to date on the results of the Woodward procedure.
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J. David Richardson, MD, Louisville, Kentucky Gerald M. Larson, MD, Louisville, Kentucky Hlram C. Polk, Jr., MD, Louisville, Kentucky
Although some controversy remains as to the procedure of choice for gastroesophageal reflux, the Nissen fundoplication has provided effective reflux control in the overwhelming majority of patients reported in the literature [I]. We prefer a transahdominal approach for routine primary repair while the transthoracic route has been reserved for complex cases such as reoperation, the possibility of carcinoma and stricture with acquired shortening of the esophagus. The shortened and often stretched esophagus represents a difficult situation, in that even with thorough esophageal mobilization to the aortic arch, the fundoplication wrap occasionally cannot be reduced below the diaphragm. In this eventuality the surgeon may elect to leave the wrap in a supradiaphragmatic position or perform an esophageal lengthening procedure using the Collis gastroplasty combined with a fundoplication [2,3]. Although anecdotal comments of favorable results or catastrophes had been made on the supradiaphragmatic fundoplication, there were no organized reports on such patients before 1980. Two patient series have now been reported in which the fundoplication was left above the diaphragm. Disastrous results were reported in one group [4]; in the other series the supradiaphragmatic fundoplication was found to be a safe, effective method of managing the difficult problem of stricture with a shortened esophagus [5]. Our experience with supradiaphragmatic fundoplication, which we initially were pleased with, has been fraught with hazard when viewed from the perspective of a longer follow-up with more pa-
From the Department of Surgery, University of LouisvilleSchool of Medicine, Louisville. Kentucky. Requests for reprints should be addressed to J. David Richardson, MD, Department of Surgery, University of Louisville School of Medicine, 530 South Jackson Street, Louisville, Kentucky 40202. Presented at the 22nd Annual Meeting of the Society for Surgery of the Alimentary Tract, New York, New York, May 19-20, 1981.
Volume 143,
January 1982
tients. This report outlines our experience with what we now feel is a treacherous solution to a challenging problem and argues strongly against its continued use. Clinical
Material
We performed over 600 fundoplications for recalcitrant esophagitis, including dilatable strictures. More than three fourths of the primary operations that were performed for conditions other than stricture were carried out through a transabdominal approach. Patients with stricture and an acquired shortening of the esophagus had operative. correction through a left thoracotomy with intraoperative dilatation of the esophagus and use of a Nissen fundoplication. The operative features of this procedure and results obtained with its use were published previously [6,7]. Over the last 6 years, we encountered 15 patients in whom we could not reduce the fundoplication below the diaphragm after completion of the fundic wrap. Three of these patients were treated with a Collis gastroplasty to “lengthen” the esophagus with a subsequent total fundoplication. Twelve patients had the fundoplication left above the diaphragm. When a wrap could not he reduced below the diaphragm, the hiatus was surgically widened so that it would not act as a point of constriction on the intrathoracic portion of the stomach. The crura were then sutured to the wrap itself to prevent herniation of other viscera into the chest. A conscious point in each procedure was avoidance of diaphragmatic constriction. All patients have been followed up to date (range 16 months to 6 years, mean 3.5 years). Results The 12 patients with a supradiaphragmatic fundoplication all had prompt relief of esophagi& symptoms and control of gastroesophageal reflux. Two patients required repetitive postoperative dilatation but are now asymptomatic and do not need continued dilatation. However, 5 of the 12 patients have had major complications after creation of the intrathoracic fundoplication. In one patient, colonic 29
Richardson et al
TABLEI
Clinical Features of Patients With Gastric Ulcer
History and Indication for Operation 65 year old woman with long dilatable stricture at 30 cm 52 year old man with esophageal stricture at 32 cm; had two previous repairs
74 year old man with esophagitis and stricture at 35 cm; previous vagotomy and pyloroplasty and crural repair 53 year old woman with stricture; one previous operation
Postoperative Interval to Diagnosis
Location of Ulcer
6mo
Lesser curvature at hiatus
12 mo
Lesser curvature above hiatus
2mo
Fundic wrap eroded into bronchus with gastrobronchial fistula
18mo
Posterior wall of stomach in chest above hiatus
paraesophageal hernia developed through the widened hiatus. Chest pain and fear of strangulation prompted reoperation with reduction of the colon to the abdomen and crural repair. The intrathoracic segment remained in the chest and the patient is asymptomatic 2 years later. Four patients developed ulcerations within the intrathoracic stomach, diagnosed 2, 6, 12 and 18 months postoperatively (Table I). Two of the ulcers were located at the hiatus on the lesser curvature, one ulcer was on the posterior wall above the hiatus, and one was in the superior portion of the fundic wrap. The ulcers were diagnosed by flexible endoscopy in three patients and by barium studies in one patient. Medical management was attempted in three patients. One patient now has a healed ulcer although it recurred on one occasion after cessation of therapy. Another had a persistent gastric ulcer that failed to respond to antacids and cimetidine, but the patient has refused further operative treatment. A third patient who did not respond to medical treatment with antacids and cimetidine had a subsequent operation with performance of Collis gastroplasty and repeated fundoplication after the initial wrap was dismantled. This patient is asymptomatic 2 years after her last operation. One patient had erosion of an ulcer in the superior portion of the fundic wrap into the left lower lobe bronchus, with a gastrobronchial fistula causing severe bilateral pneumonia. Despite division of the fistula and resection of the damaged lung, the patient died from unrelenting pulmonary sepsis. An investigation of gastric emptying was undertaken in the three patients who did not have life-
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Possible Cause Delayed gastric emptying on technetium scan Difficult dissection. Possible vagal injury. Upper gastrointestinal normal emptying stomach Previous vagotomy. No obstruction on barium upper gastrointestinal study. Clearance study not done Gastric emptying normal on technetium study
Treatment
Outcome
Antacids, cimetidine, metoclopramide Antacids, cimetidine
Reoperation: left thoracotomy, division of fistula, left lower lobectomy, gastroplasty Initial medical treatment with antacids, cimetidine required. Reoperation with Collis gastroplasty
Persistent gastric ulcer until metoclopramide started. Now healed. Ulcer healed and recurred. Now healed. Asymptomatic
Died, pulmonary sepsis after reoperation
Asymptomatic 2 years postoperatively
threatening complications. Two patients had technetium-99m sulfur-colloid labeled chicken liver scans to measure the solid phase of the gastric emptying. One patient had delayed gastric emptying that improved with metoclopramide, while another patient had normal gastric emptying. A third patient had only a barium study of gastric emptying. In our series of over 600 patients with Nissen fundoplication we have had 10 recurrences of hiatal hernias. Three of these 10 patients have had gastric ulceration within the herniated segment. Only two of our patients without a recurrence of hiatal hernia have had gastric ulcer. Case Reports 1. A 65 year old woman had severe dysphagia for 8 months and a 4 year history of mild dysphagia. A midCase
esophageal stricture was present on barium swallow and the fiberoptic endoscope would not advance beyond a stricture at 30 cm. Brushings and biopsy of the stricture were negative for carcinoma. A left thoracotomy was performed and a benign stricture was found, which was dilatable to size 46 French. A fundoplication was performed over the dilator, but the shortened esophagus precluded abdominal placement of the wrap. The fundoplication was left in the chest. The patient had marked early improvement and was discharged on a regular diet without dysphagia. She required dilatation on three subsequent occasions. Six months after the operation she had upper gastrointestinal hemorrhage. An upper gastrointestinal series showed a large gastric ulcer on the lesser curvature at the level of the hiatus (Figure l), which was substantiated by flexible endoscopy (Figure 2). Antacids and cimetidine were employed for several months with improvement in symptoms, but the ulcer did not completely heal. Subsequently, technetium sulfur-colloid scan showed
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lntrathoracic Fundoplication
Figure 2. Endoscopk vlew of the lntrathorack gastrk segment, which was prompted by upper gastrolntestlnsl hemorrhage and disclosed a large, deep ulcer at the level of the hlatus (arrows).
F@aw 7. Barium study demonstrates dllatatkn of the upper porikn of ths stomach ( white anvws) de@e careful attempts to prevent constrktkn at the diaphragm. A large ulcer is present at the level of the hiatus (black arrow).
delayed gastric emptying that improved with metoclopramide (Figure 3). The ulcer has now completely healed, documented by endoscopy and barium studies, although she continues to require occasional esophageal dilatations. Comment: There was good evidence to support the diagnosis of delayed gastric emptying in this patient. Whether or not inadvertent injury to the vagus nerve was the casue of this phenomenon is unknown, but the favorable response to metoclopramide and the healing of a long-standing gastric ulcer suggested that vagotomy was potentially responsible. Case 2. A 74 year old man with a long history of severe heartburn was admitted for progressive dysphagia and weight loss. He had undergone vagotomy and pyloroplasty 12 years before to “reduce gastric acidity” and provide symptomatic relief of heartburn. Ten years earlier transthoracic crural repair had been performed. Neither procedure had afforded significant improvement in symptoms. Endoscopy disclosed a stricture at 35 cm with severe ulceration of the esophagus. The stricture was easily dilatable to size 44 French. Transthoracic fundoplication was performed, but the wrap was left in the left hemithorax because of esophageal shortening. The initial postoperative course was smooth, and the patient had relief of heartburn and dysphagia. Two months later he developed acute left chest pain, prompting admission to a coronary care unit. However, electrocardiographic and cardiac enzyme studies were normal and fiberoptic endoscopy was performed. No ulceration of the stomach was detected, and there was near-total healing of the esophagus, which previously had been severely inflamed. Two days after admission, the patient developed fulminant bilateral pneumonia and re-
Volume 143, January 1992
quired ventilatory support. An air leak into the gastrointestinal tract prompted radiologic evaluation (Figure 4). A gastrobronchial fistula was present, which filled both the right and left lungs with contrast material through the left lower lobe bronchus. Reoperation was performed and a large gastric ulcer in the superior portion of the fundic wrap was found. The ulcer had eroded into the left lower lobe of the lung with a fistulous communication from the stomach to the lower lobe bronchus. The lower lobe was resected, the ulcer was closed in two layers, the fundoplication was dismantled, and a Collis-Nissen procedure was performed. The patient continued to have bilateral necrotizing pneumonia and died from pulmonary failure.
NORMAL
L.L.
L.L. (metoclopram!de)
Figure 3. Gastrk mot/My. Gastric emptybtg In our patient (L.L.) was slower than in other normal controls, as measured by technetium-99m. Metoclopramlde converted emptying toward the normal range.
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Richardson et al
omy. An upper gastrointestinal series did not demonstrate gross evidence of gastric obstruction, but quantitative studies of gastric emptying were not performed.
Figure 4. Preoperative barium swallow discloses a long strkture with marked proximal dllatatlon of the esophagus. Dlvertkula are present (arrows).
Case 3. A 57 year old man presented with a I5 year history of epigastric and retrosternal burning pain after eating, which had increased in frequency and severity. In addition, he could swallow only liquids. A barium swallow showed an extremely shortened esophagus with a long distal stricture (Figure 5) which could only be dilated to a size 22 French. Transthoracic fundoplication was performed after intraoperative dilatation to a 36 French caliber; however, due to the severe shortening, the fundoplication could not be reduced into an intraabdominal position and was left in the chest. Postoperatively the patient had prompt relief of heartburn and improvement in dysphagia. Dilatation was required twice for the first 2 months after operation and was easily performed to a size 42 French. He required an additional dilatation 10 months postoperatively and is presently asymptomatic and eating a regular diet. A barium swallow 16 months after operation showed an area of persistent narrowing but was greatly improved over the preoperative study (Figure 6). Comment: This case was included for contrast to the two previous case histories because it demonstrates the occasional gratifying result that can be obtained with supradiaphragmatic fundoplication. We feel that close observation of this patient is required to prevent complications if ulceration of the intrathoracic stomach should occur.
Comments Comment:
This lethal complication might have been prevented by immediate recognition of the cause of the chest pain and operative treatment of the ulcer. “Normal” results of endoscopic examination led us to believe that the pain was not due to a postoperative complication. Whether delayed gastric emptying can be implicated is problematic; nonetheless, the patient had previously undergone vagot-
Flgure 5. Preopera tlve barium 8 walk w dlscloses a kng strkture wlth marked proximal dllatatkn af the es@agos. Dlvertkula are present ( arrow ) .
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The results fundoplication complications
achieved with intraabdominal Nissen are excellent [8-101, with few major reported. However, there is relatively
Flgure 6. Postoperative study disclosed some lessening of the strkture and less proximal dllatatlon. 77te patient’s Improvement In symptoms was more dramatk than the radkgraphk Improvement.
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little in the surgical literature to document either the safety or the danger of leaving the fundoplication above the diaphragm in acquired short esophagus. Hollenbeck and Woodward [l I] described 45 combined fundic patch-fundoplication procedures, of which several cases required that the wrap be left in the chest. They reported no complications with this maneuver. At a recent international symposium on esophageal diseases, Woodward [12] stated that he had no complications with the intrathoracic segment of wrapped stomach. Pennell [5] described the “floppy Nissen” fundoplication as an effective means of controlling reflux strictures when the wrap is left in a suprathoracic position, reporting 10 cases in which the patients had a good result without complications. However, he did note that two of the six patients with so-called “conventional or snug Nissen fundoplication” developed ulceration and bleeding when the wrap was left above the diaphragm. Although there have been anecdotal discussions of the hazards of an intrathoracic fundoplication, there are few reports of complications with such an approach. Mansour et al [4] recently described an experience with disastrous complications after supradiaphragmatic placement of a fundoplication. One of four patients in their series with a Thal-Nissen (fundic wrap fundoplication) procedure had intrathoracic rupture of the stomach with a gastrobronchial fistula similar to that reported in our series. Ten additional patients had a fundoplication left in the chest, and 4 had severe complications. One had lesser curvature ulceration requiring gastrectomy, one had a herniation of the wrap producing gastric outlet obstruction, and two had intrathoracic gastric rupture leading to death. Rupture and fistulization from the fundoplication segment have been reported by others [13,14], but these complications have generally followed an abdominally placed fundoplication. Burnett et al [15] reported a much higher complication rate after transthoracic fundoplication, but these problems did not seem to be related to a supradiaphragmatically placed gastric wrap. Henderson (personal communication) treated three referral patients with previously placed interthoracic fundoplications who developed severe complications. One died from gastric perforation and two required urgent operation for correction of hemorrhage. Ulceration of the stomach in a patient previously treated by fundoplication has been reported, even when the wrap was left below the diaphragm. Bushkin et al [16] reported on 5 patients (3.1 percent) with gastric ulcers of the lesser curvature in a series of 160 patients undergoing Nissen fundoplication. This complication was not observed in 200 patients who underwent the Allison or posterior gastropexy method of hiatus hernia repair. Bremner [17] noted four instances of gastric ulceration in 43 patients after the Nissen fundoplication. We have now observed gastric ulceration in only 4 of 600 patients
Volume 143, January 1982
treated by Nissen fundoplication if the hiatus hernia did not recur. If, as the available reports suggest, there is a slightly increased incidence of gastric ulceration after abdominal fundoplication, there are several possible mechanisms to explain this phenomenon. Bushkin et al [16] implicated the gas-bloat syndrome and noted that four of their five patients who developed gastric ulcers after a Nissen procedure had coexistence of the two problems. They theorized that the bloating resulted in antral distention with increased gastrin release, although gastrin levels were not measured. Vagal injury with delayed gastric emptying was implicated as the cause of ulceration in the other patient. Twenty-four hour pH studies, which showed alkaline gastric contents, caused Bremner [17] to suggest that bile reflux may be responsible for the 10 percent incidence of gastric ulcers seen after Nissen fundoplication in his series. Finally, careful clinical studies from the laboratory of Little et al [18] showed that gastric emptying is abnormally delayed in unoperated patients with gastroesophageal reflux. This suggests that the somewhat higher incidence of gastric ulceration after fundoplication may be related to gastric stasis rather than to a postoperative abnormality induced by the procedure itself. When the fundoplication is left in the chest there are at least three possible explanations for the observed high incidence of ulceration and perforation: (1) negative intrathoracic pressure which promotes distention of the wrap causing gastrin release as well as delayed emptying and potential ulceration, (2) constriction of the stomach at the hiatus with delayed emptying, and (3) vagal injury with subsequent retarded emptying. The effects of negative intrathoracic pressure on the stomach have not been well studied, but this has not been a particular problem for patients with esophagogastrostomy for carcinoma. However, short survival time and the absence of a 360” wrap may make this analogy invalid. The hypothesis that negative intrathoracic pressure alone contributes to gastric ulceration would explain the fairly high incidence of ulceration we have seen in patients with recurrent hernias and a gastric segment in the chest (three ulcers in 10 recurrences). In our patients with an intrathoracic fundoplication, we went to great lengths to avoid gastric constriction at the hiatus. Therefore, we do not believe hiatal constriction contributed to the observed complications. The possibility of vagal injury is real and must be strongly considered in two of our patients. One had a deliberate vagotomy many years before, and the other had a difficult dissection of the esophagus with demonstrated delayed gastric emptying postoperatively. The superimposition of a vagal injury in a patient who had no pyloroplasty may be sufficient to lead to ulceration. However, we had an additional patient with ulceration who had normal gastric emptying on technetium scan, indi-
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Richardson et al
eating that this mechanism does not provide a satisfactory solution for even our small series of complications. Our experience, combined with the few other published reports, suggest that a fundoplication placed in the chest is not a reasonable alternative for a shortened esophagus due to chronic gastroesophageal reflux. We have been slow to recommend the routine use of the gastroplasty combined with a fundoplication in uncomplicated hiatus hernia cases as has been advocated by some groups, because we have seen in our referral practice several instances of fistula from the staple line and one case of neartotal gastric necrosis after this procedure. However, the inability to reduce effectively the wrap below the diaphragm is a clear-cut indication for gastroplasty followed by fundoplication. Although our experience with this approach is limited, it has been successful, and that, coupled wih the more extensive favorable reports [2,3] suggests that this option is preferable to the treacherous alternative of leaving the wrap above the diaphragm. Summary Intrathoracic fundoplication was used in 12 patients with acquired shortening of the esophagus secondary to gastroesophageal reflux. While several patients had excellent results using this approach, five major complications occurred. One patient developed a paraesophageal hernia, while four had ulceration within the wrap itself. One had serious hemorrhage, while another required reoperation to dismantle the intrathoracic wrap. One patient developed a gastrobronchial fistula and eventually died from pulmonary sepsis. The cause of these problems is unknown, but delayed gastric emptying was implicated in two patients. Even though leaving a Nissen fundoplication in the chest seems to be an attractive alternative when the surgeon cannot reduce the wrap below the diaphragm, this alternative is fraught with treacherous complications in a large percentage of patients. References 1. Ellis FH Jr. Controversies regarding the management of hiatus hernia. Am J Surg 1980;139:782-8. 2. Ellis FH Jr, Leonardi HK, Dabuzhsky L, Crozier RE. Surgery of the short esophagus with stricture. An experimental and clinical manometric study. Ann Surg 1978;188:341-50. 3. Orringer MB, Sloan H. Combined Collis-Nissen reconstruction of the esophogogastric junction. Ann Thorac Surg 1978; 2516-21. 4. Mansour KA, Burton HG, Miller JI Jr, Hatcher CR Jr. Complications of intrathoracic Nissen fundopkation. Ann Thorac Surg 1981;32:173-8. 5. Pennell TC. Supradiaphragmatic correction of esophageal reflux strictures. Ann Surg 1981;193:655-65. 6. Polk HC Jr, Zeppa R. Hiatal hernia and esophagitis: a survey of indication for operation and technic and results of fundoplication. Ann Surg 1971;173:775-81. 7. Polk HC Jr. Fundoplication for reflux esophagitis. Misadventures with the operation of choice. Ann Surg 1976;183:645-52.
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8. DeMeester TR, Johnson LF, Kent AH. Evaluation of current operations for prevention of gastroesophageal reflux. Ann Surg 1974;180:511-5. 9. Dilling EW, Peyton MD, Cannon JP, Kanaly PJ, Elkins RC. Comparison of Nissen fundoplication and Belsey Mark IV in the management of gastroesophageal reflux. Am J Surg 1977;134:730-3. 10. Ellis FH Jr, El-Kuro MF, Gibb SP. The effect of fundoplication on the lower esophageal sphincter. Surg Gynecol Obstet 1976;143:1-5. 11. Hollenbeck JI. Woodward ER. Treatment of peptic esophageal strictures with combined fundic patch fundoplication. Ann Surg 1975;182:472-8. 12. Woodward ER. Surgical treatment of stricture complicating gastroesophageal reflux. In: Stipa S, Belsey RH, eds. Medical and surgical problems of the esophagus. New York: Academic Press, 1981. 13. lkard RW, Jacobs JK. Gastropericardial fistula and pericardial abscess. Unusual complications of subphrenic abscess following Nissen fundoplication. South Med J 1974;67: 17-9. 14. Mullen JT, Burke EL, Diamond AB. Esophagogastric fistula. A complication of combined operations for esophageal disease. Arch Surg 1975; 110:826-8. 15. Burnett HI, Read RC, Morris WD, Campbell GS. Management of complications of fundoplication and Barrett’s esophagus. Surgery 1977;82:521-30. 16. Bushkin FL, Woodward ER, O’Leary JP. Occurrence of gastric ulcer after Nissen fundoplication. Am Surg 1976;42:8216. 17. Bremner CG. Gastric ulcer after the Nissen fundoplication. Surg Gynecol Obstet 1979;148:62-4. 18. Little AG, DeMeester TR, Kirchner PT, O’Sullivan GC, Skinner DB. Pathogenesis of esophagitis in patients with gastroesophageal reflux. Surgery 1980;88:101-7.
Discussion Tom R. DeMeester (Chicago, IL): As Dr. Richardson pointed out, this problem occurs in only about 10 percent of the patients who have an antireflux procedure and only in about one fourth of these patients does the reconstruction need be left in the chest. This occurs for two reasons. First, it is a big step to go from an antireflux reconstruction that cannot be reduced into the abdomen, to a colon interposition, particularly if one’s experience with colon interposition is minimal. Thus, most surgeons are eager to find a simpler solution, Second, we have known for years that a hiatus hernia is a condition in which the stomach is in the chest without any known problem, and therefore, we reason, why not leave a fundus wrap in the chest? But this logic is fallacious for the following reasons: In a hiatus hernia, the phrenoesophageal membrane makes up the hernia sac and serves as an extension of the abdominal cavity into the chest so that the stomach in the hernia sac is actually in the abdomen and under abdominal pressure. When the hernia sac is removed during the construction of a Nissen fundoplication and the reconstruction is left in the chest, a differential pressure develops between the luminal aspect of the stomach and the pleural cavity with only the stomach wall in between. As a consequence of the reconstructed competent cardia and the negative intrapleural and positive intraabdominal pressure, the stomach gradually dilates into the chest. An air-fluid level can occur in the stomach, indicating gastric retention and the potential for the development of an ulcer. As a consequence, a repair left in the chest is subject to all the complications of a paraesophageal hernia: ulceration, strangulation, perforation and bleeding. I am grateful that
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the authors had the courage to report the catastrophies they had in leaving a Nissen fundoplication in the chest. This experience is a lesson that all should remember. Finally, I am not sure whether Collis gastroplasty is the proper way to handle this problem. It is our view that adequate mobilization often will allow the repair to be placed under minimal tension into the abdomen. This may require mobilization above the aortic arch and division of pulmonary branches of the left vagal nerve. If after these maneuvers we are unable to reduce the repair into the abdomen, we prefer to use a short colon interposition. Philip Donahue (Chicago, IL): This report clearly describes some of the problems of the intrathoracic Nissen procedure, and the explanation given is one we would agree with, namely, that the incarcerated segment and poor gastric emptying in the supradiaphragmatic segment lead to stasis and ulceration. We avoid this problem whenever possible at the University of Illinois. When we use the Collis procedure we usually use a modified Collis procedure not dividing the stomach after applying the stapler but merely wrapping the stomach around the esophagus, and we find that satisfactory in most cases. The second group of patients in this presentation are the ones I would like to discuss at some length, namely, those whose intraabdominal wrap migrates into the thorax. This report emphasizes that crural repair with nonabsorbable sutures must precede any attempt at formal fundoplication, usually by the abdominal route, and if it is done by the thoracic route then the crural repair has to be done after fundoplication, after the wrap has been reduced beneath the diaphragm. The question I have for the authors is this: Do you take any special steps to identify patients postoperatively whose wrap has migrated through the hiatus? Do you mark the wrap with small metal clips or do you perform serial roentgenographic examinations to determine which patient’s wrap has migrated through the hiatus? I think the incidence of such asymptomatic migrations is somewhat higher than the less than 5 percent quoted in this study, and perhaps this group of patients should be identified in some way as a high risk group for complications of herniated Nissen fundoplication. Timothy C. Pennell (Winston-Salem, NC): Dr. Polk and his confreres have contributed greatly to our understanding and management of esophageal reflux over the years. Supradiaphragmatic Nissen fundoplication will work, and will work safely when properly done. Our series was 16 patients; only 2 had less than 18 months’ follow-up, and the longest follow-up was 8 years. There are three essentials if one is forced to leave a fundic wrap above the diaphragm. One is that the hiatus must be sufficiently patulous to introduce at least four fingers and preferably the entire fist through the hiatus. The second thing is that the fundoplication must be “floppy.” The hiatal ring must be secured appropriately to the gastric wall as the wall passes through the hiatus. When these principles were followed there were no com-
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Fundoplication
plications. This is not a procedure to be done electively, but I think it can be done before interposition. I congratulate the authors again, particularly on the concept that we must look at other factors related to the cause of complications. Is it more than just obstructive stasis from basically a blind loop obstruction? Paul H. Jordan (Houston, TX): When you bring the stomach through the hiatus, what precautions do you take in order to make the hiatus large enough? I have been under the impression that if you make a radial incision in the diaphragm and tack the diaphragm around the stomach, you don’t have this problem if the opening is sufficiently large. I wonder how large you make this opening. James Maher (Jackson, MS): I would like to say a word or two in defense of the intrathoracic fundoplication. Ed Woodward and I recently looked up the results of our Thal-Nissen procedures. We now have 69 patients with an average follow-up of 5 years. There have been two diaphragmatic hernias but no gastric ulcerations in the intrathoracic stomach. We have, however, seen gastric ulcerations in patients with intraabdominal fundoplication. This is a well-described syndrome, with no apparent predilection for intrathoracic fundoplication. The data on gastric retention were very interesting. We recently had a patient who presented with gastric ulceration after transabdominal fundoplication, in whom we were able to demonstrate gastric retention of solids and postprandial hypergastrinemia with subsequent formation of a “Dragstedt ulcer” from gastric stasis. I would like to ask the authors whether or not the isotopic emptying method they used measured gastric emptying of solids or liquids, since there is a difference between the two that should be addressed. J. David Richardson (closing): Dr. DeMeester, we always mobilize the esophagus completely. We believe that we would not be able to reduce the wrap below the diaphragm otherwise. However, we do find an occasional patient, as we reported today, in whom even with supraaortic mobilization, one simply cannot reduce the fundoplication below the diaphragm. In that setting, inadvertent vagal injury is almost always a possibility. Regarding the question about slippage of the wrap above the hiatus, we note that we do close the crura in all patients. We do not place clips about the fundoplication, but we routinely study all patients at both 6 and 12 months and have not found the problem of the Nissen wrap slipping back into the chest. A question was asked about gastric emptying, which we measure in the solid phase using technetium sulfur colloid. Our operative technique is almost identical to that described by Dr. Pennell, except that we don’t use quite as big a dilator, preferring a size 44 instead of a 56. We open the hiatus to where it is patulous and cannot constrict the stomach. We asked Dr. Woodward to discuss the report because of the apparent discrepancy between his results and ours, and are glad he sent a representative to bring us up to date on the results of the Woodward procedure.
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