- Email: [email protected]
Reoperation for complications of the Nissen fundoplication
J
THORAC CARDIOVASC SURG
81:50-56, 1981
Reoperation for complications of the Nissen fundoplication Case histories I~( 25 patients are reported ill whom complications after a Nissen fundoplication were sufficiently severe to require reopcration. Patients were classified by complications as having postoperative dvsphagia (14), recurrent reflux (.1'1'\'1'11), "Ras bloat' syndrome (two), and paraesophageal hernia (two). Six I~( the 14 patients with dysphagia had 110 esophageal peristalsis, 0111' had a panmural fibrous stricture, 0111' had a ' 'slipped" Nissen, and ill six the wrap lI'as presumed to IWI'e been fashioned too tight!v. Too tight a wrap was also responsible for the .1'£,\'1'11 instances ojrecurrent reflux and the two of ' 'gas bloat" syndrome. Revision of the fundoplication relieved the symptoms ill the 15 patients ill whom it was don l' . A variety I~( surgical procedures were performed Oil the other 10, all but 0111' o( whom experienced a Rood result, Proper selection ojpatientsjor operation coupled with attention to certain technical surgical details will ensure Rood results in 90'7c ofpatients after a Nissenfundoplication.
Howard K. Leonardi, M.D., Robert E, Crozier, M.D., and F. Henry Ellis, Jr., M.D., Ph.D" Burlington, Mass.
Antireflux operations are now widely employed for symptomatic relief of gastroesophageal reflux unresponsive to medical treatment. Differences of opinion exist, however, as to which sphincter-enhancing procedure is best. Although experimental': 2 and clinical":" studies suggest that the Nissen fundoplication is superior to the others in correcting reflux, it has been criticized by some as being unusually susceptible to postoperative complications, such as the "gas bloat" syndrome, dysphagia, recurrence of reflux, or displacement of the fundic wrap. 6-H This study was undertaken to classify these postfundoplication complications on the basis of our experience with patients requiring reoperation and to suggest means of minimizing their occurrence.
Patients and methods of analysis Twenty-five patients who had undergone a Nissen fundoplication required reoperation for a variety of From the Departments of Thoracic and Cardiovascular Surgery (Dr. Ellis) and Gastroenterology (Dr. Crozier), Lahey Clinic Medical Center, Overholt Thoracic Clinic (Dr. Leonardi), and Departments of Gastroenterology (Dr. Crozier) and Thoracic and Cardiovascular Surgery (Drs, Leonardi and Ellis), New England Deaconess Hospital, Boston, Mass, Read at the Sixth Annual Meeting of The Sampson Thoracic Surgical Society, Durango, Colo" June II to 14, 1980. Address for reprints: F, Henry Ellis, Jr., M.D,. Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, 41 Mall Rd., Burlington, Mass. 01803.
50
Table I. Complications of Nissen fundoplication requiring reoperation Dysphagia Aperistalsis Achalasia Diffuse esophageal spasm Scleroderma "Slipped" Nissen Peptic stricture Idiopathic Recurrent reflux "Gas bloat" syndrome Paraesophageal hernia Total
14 6
4 I
I I I 6
7
2 2 25
complications. Eight of the patients had been operated upon originally by us, and 17 patients had undergone operation elsewhere. The fundoplication had been performed between 3 and 38 months before reoperation, the postoperative interval averaging 16 months. Four of the 25 patients had had multiple previous operations on the esophagogastric junction totaling 12, including three Heller esophagomyotornies, two Allison hiatal hernia repairs, and seven Nissen fundoplications. The nature of the original antireflux operation was determined by careful scrutiny of the operative reports and by the findings at reoperation. Preoperative evaluation of the patient stressed esophageal manometry by techniques described elsewhere" as well as the usual roentgenographic and endoscopic studies. All patients
0022-5223/811010050+07$00.7010 © 1981 The C. V. Mosby Co.
Volume 81 Number 1 January, 1981
Nissen fundoplication
51
Table II. Manometric studies of lower esophageal sphincter Postoperative
Preoperative Category
No.*
Pressures (mm Hg)
Dysphagia Esophageal aperistalsis Idiopathic Miscellaneous Recurrent reflux "Gas bloat" Control Nissen Normal
6 6 2 7 2 38 14
20.0 15.0 16.0 6.3 16.5 16.1 12.7
I
Lengtht (em)
No.*
Pressuret (mm Hg)
3.5 3.2 3.5 3.3 6.5 4.4 3.5
5 6
11.0 15.0 15.0 20.4 13.0
I
6 2
I
Lengtht (em)
3.0 3.5 3.0 3.8 3.0
* Number of patients studied. t Recorded as mean values.
were available for follow-up analysis, which included clinical assessments in 25 patients, esophageal manometry in 20 patients, and barium contrast esophagography in 13 patients. The follow-up intervals varied from 3 months to 9 years, averaging 2.8 years. Classification of complications and results Although each patient requiring operation after a "failed" Nissen fundoplication presented certain unique problems not necessarily common to others, it was possible to classify the postoperative complications into general categories as listed in Table I. In Table II the preoperative and postoperative manometric findings are listed, as are those in normal individuals and those in patients after an uncomplicated Nissen fundoplication previously reported. 10 Dysphagia. Fourteen patients, seven of whom had no symptoms of dysphagia preoperatively, had severe dysphagia after fundoplication. Esophageal manometry disclosed no abnormalities of the lower esophageal sphincter (LES) but identified an underlying motility disorder characterized by aperistalsis of the esophagus in six patients. The motility pattern was diagnostic of achalasia in four patients, each of whom was initially operated upon for dysphagia incorrectly ascribed to distal esophageal narrowing by peptic stricture. A similar motility pattern was identified in a fifth patient in whom accompanying dermatologic findings suggested the diagnosis of scleroderma. Diffuse spasm of the distal half of the esophagus was manometrically evidenced in an additional patient. A "slipped" Nissen was suspected in one patient in whom two distinct distal high-pressure zones were discernible, and in another patient dysphagia was caused by severe narrowing of the distal esophagus by a long peptic stricture. The cause of dysphagia was categorized as idiopathic in the remaining six patients because
no abnormalities could be identified preoperatively by esophageal manometry, endoscopy, or roentgenography, and repeated dilations were ineffective. The corrective procedure was individualized in each patient and was most complex in the subset of patients with esophageal aperistalsis. In this subset reoperations included takedown of the previous Nissen in two patients, conversion to a Collis-Belsey repair in two patients, total esophagectomy with colon interposition in one patient, and a long esophagomyotomy in one patient. An additional patient with a severe peptic stricture required an esophagogastrectomy for relief of dysphagia. In the remaining seven patients, revision of the previous Nissen fundoplication was performed. Thirteen of 14 patients reported satisfactory relief of dysphagia, and one patient with advanced scleroderma had mild residual symptoms of dysphagia. An analysis of manometric data within the category of patients with dysphagia disclosed differences between preoperative and postoperative LES characteristics only within the esophageal aperistalsis group, in whom postoperative LES pressures were lower. Recurrent reflux. Symptoms of recurrent reflux occurred in seven patients after fundoplication at intervals of 4 to 36 months, averaging 19 months. Preoperative manometry disclosed hypotensive LES pressures in all patients, with values ranging from 3 to 10 mm Hg and averaging 6.3 mm Hg (Table II). At reoperation, complete disruption of the fundoplication was evident in five patients, and partial disruption, resulting in a less than circumferential wrap, had occurred in two. Reconstruction of a circumferential wrap was performed in each patient. All patients reported relief of reflux symptoms postoperatively, and mean postoperative LES pressures were increased approximately threefold over preoperative values. "Gas bloat" syndrome. "Gas bloat" syndrome
52
The Journal of Thoracic and Cardiovascular Surgery
Leonardi, Crozier, Ellis
serious enough to require reoperation occurred in two patients 8 months and 12 months after Nissen fundoplication. Both patients had experienced satisfactory relief of previously intractable reflux symptoms but had complained repeatedly of an inability to belch. Although motility studies disclosed normal LES pressures in both patients, the high-pressure zone in one patient extended over a longer length of distal esophagus than we consider optimal (7 em as opposed to 3 to 5 em). In this patient, the wrap was revised so as to include only the distal 3 em of esophagus. In the second patient, the Nissen fundoplication was converted to a Hill posterior gastropexy. Both patients reported relief of their disturbing preoperative symptoms after these revisions. Postoperative manometry disclosed normal LES pressures while LES length had been reduced by more than one half when compared with the preoperative length (Table II). ParaesophageaI hernia. Paraesophageal hernia developed in two patients at intervals of 2 years and 3 years after fundoplication. One patient who was asymptomatic was recommended for operation in view of the risk of serious sequelae should strangulation of the herniated distal stomach occur. The second patient reported intermittent epigastric and retrosternal discomfort and occasional nausea without vomiting for several weeks. Neither patient had experienced symptoms of recurrent reflux, and motility studies were not performed. Transabdominal reduction of the herniated stomach and retroesophageal suture narrowing of the diaphragmatic crura were performed successfully in both patients with relief of symptoms.
Surgical technique Although the technical details of the performance of a Nissen fundoplication have been published extensively by US 1l1- 12 elsewhere and will not be reviewed in detail here, several aspects of the procedure merit reemphasis. Adequate transabdominal mobilization of the distal 5 to 7 em of esophagus without vagal injury is essential for proper location of the fundic wrap. The mobilized esophagus is encircled by an elasticized tape and held in gentle inferior traction while a fundic wrapping maneuver without tension is facilitated by division of several of the uppermost short gastric vessels as well as the gastrohepatic ligament. An intraluminal stent of adequate caliber (our preference is a No. 40 Fr. mercury-filled bougie) is essential for avoidance of an unduly tight wrap. Inferior displacement of the wrap is discouraged by including esophageal musculature between the sero-
muscular gastric sutures. Further stabilization of the wrap is achieved by placing sutures between the superior rim of the wrap and esophageal muscle circumferentially. A crural repair with heavy, nonabsorbable sutures should also be performed if the esophageal hiatus admits more than the tips of two fingers. Nasogastric suction is not routinely employed in the postoperative period but may be of value in some instances to avoid gastric distention, which may threaten the integrity of the newly constructed fundoplication. Adherence to these principles, coupled with proper patient selection, should lead to gratifying results in the majority of patients. This at least has been our experience with 77 fundoplication procedures including the 15 Nissen revisions reported here. Symptomatic reflux has been relieved completely and permanently in all but four patients (95%) over a follow-up period averaging 4.2 years. Four other patients had unsatisfactory results, for an overall success rate of 90%.
Discussion The introduction of new surgical procedures is usually accompanied by a period of experimentation in which the originally described technique undergoes modifications before it is ultimately standardized into a procedure that can give predictably good results. The Nissen fundoplication is no exception, for the 360 degree wrap of the distal esophagus with anterior and posterior walls of the adjacent gastric fundus has undergone a number of modifications, including the incorporation of highly selective vagotomy, 1:1 wrapping of less than 360 degrees of the stomach, I~ use of the anterior gastric wall alone, I:; and the employment of posterior gastropexy in association with fundoplication.!" These many modifications make it difficult at reoperation to determine what actually was performed at the first procedure and emphasizes the need for standardization of the operation if good results are to be uniformly achieved. Evidence for this is provided by the fact that we have had to reoperate upon 25 patients, some of them our own, who had had an unsuccessful "Nissen" operation. The complications leading to reoperation in this series have been classified on the basis of symptoms, in the hope thereby to obtain insights into the causes of failure and clues as to their avoidance. Reoperation was necessitated in more than half of the patients by postoperative dysphagia. Transient dysphagia beginning between the seventh and the tenth postoperative days is a well-recognized phenomenon, presumably resulting from postoperative edema, 10. 17 but rarely proves to be
Volume 81 Number 1 January, 1981
a significant clinical problem. The dysphagia experienced by the patients requiring reoperation was persistent. Its main cause was improper application of an antireflux procedure to patients with absence of peristalsis in the body of the esophagus. The importance of adequate preoperative assessment of the patient about to undergo an antireflux maneuver, particularly with regard to esophageal motility, cannot be overemphasized. The term "slipped" Nissen has been adopted widely since its introduction to describe cases in which the wrap surrounds gastric corpus rather than distal esophagus.!" We suspect it usually occurs, as it did in one of our patients, because of inadequate mobilization of the distal esophagus with performance of the wrap around the stomach itself rather than by slippage of the wrap from esophagus above to stomach below. Whatever the cause, it leads to obstructive symptoms, which can be relieved only by repositioning the wrap in its proper location. Although some have advocated performing a Nissen fundoplication around a fibrous stricture;'? we have found that, at least in instances of firm panmural fibrosis, such a procedure is ineffective, as it was in one of our patients. Currently, we prefer to employ a Collis gastroplasty so that the Nissen fundal wrap can be fashioned around pliable, healthy tissue. Adequate control of reflux and effective dilation of the stricture are thereby ensured." Six of the patients with persistent postoperative dysphagia as a cause for reoperation did not have this symptom preoperatively, and careful postoperative assessment including endoscopy, esophageal manometry, and radioscopic examination of the upper gastrointestinal tract failed to reveal the cause of this persistent and disabling symptom. We assume that the original wrap was fashioned too tightly in these individuals, but current investigative techniques are not sophisticated enough to measure this variable. Symptoms were relieved in these patients by taking down the original wrap and refashioning it more loosely. The importance of a loose wrap in avoiding complications has convincing experimental support. 20 Too tight a wrap may predispose to breakdown of the fundoplication and recurrent reflux, a complication that occurs in about 10% of patients in some series. 14. 21 Although such breakdowns usually appear within the first postoperative year, 17 one of the recurrences we are reporting did not occur until 3 years after operation. In all seven of our patients with reflux as a cause of reoperation, the previously placed sutures were found to have pulled through the gastric wall. The LES pres-
Nissen fundoplication
53
sures were in the hypotensive range preoperatively in all and were restored to high normal levels by revision of the fundoplication with relief of symptoms. Although persistent postoperative reflux may be the result of too loose a wrap," we encountered no such case in this series, probably because we have avoided the use of too large a stent. Too tight a wrap is probably also responsible for the "gas bloat" syndrome, which occurred in as many as 54% of Woodwards'" original series, although with further follow-up review the incidence was reduced to 13%.21 In our!" experience and that of others ,!? this complication has been rare. The only manometric abnormality identifiable in our two patients was an excessively long wrap in one. Both were relieved of symptoms by revision of the fundoplication. Experience with another patient not requiring reoperation suggests that another cause may be placement of the fundoplication within the chest, with obstruction developing at the diaphragmatic level. Although we originally had considered intrathoracic fundoplication as a reasonable undertaking in patients with a shortened esophagus, experience with this patient has led us to perform a Collis gastroplasty as an esophageal lengthening procedure in such instances; we fashion the Nissen wrap around the neoesophagus in the abdomen, rather than resorting to an intrathoracic fundoplication. The need for adequate narrowing of the patulous hiatus in patients with reflux and a hiatus hernia undergoing a Nissen procedure is emphasized by two of our patients in whom a postoperative hernia developed, a complication previously described.F These patients experienced the usual postprandial symptoms of a paraesophageal hernia, which were relieved by reduction of the hernia and adequate narrowing of the esophageal hiatus. Other complications have been described, such as gastric ulceration;" gastric leaks resulting in peritonitis with fistulous communication with other viscera (bronchus or pericardium), 6. 25. 26 and esophagogastric fistulas between the fundoplication and adjacent esophagus." Such complications, which we fortunately did not encounter, probably are due to impairment of the blood supply of the gastric fundus and to the placement of deep necrosing sutures in the esophagus. The growing list of postfundoplication complications suggests that insufficient emphasis has been placed on the technical details that make the Nissen fundoplication both safe and effective. We still believe that, when properly performed, the 360 degree wrap of the distal
The Journal of
54
Leonardi, Crozier, Ellis
3.5 to 5 em of esophagus by adjacent gastric fundus (classic Nissen operation) is the preferred method of treatment of symptomatic gastroesophageal reflux resistant to medical therapy. For it to be successful, however, certain precautions are essential. Accurate preoperative diagnosis is necessary to avoid its performance on the aperistaltic esophagus. Also to be avoided are patients with hard panmural fibrous strictures, in whom the compressive effect of the Nissen wrap has proved to be ineffective. The wrap should be performed over a large-bore (No. 40 Fr.) tube to prevent overzealous tightening, which might result in postoperative dysphagia, the "gas bloat" syndrome, or breakdown of the wrap with recurrent reflux. Although some prefer a larger stent, the risk of persistent reflux might thereby be increased. Rather than fashion the fundoplication around a shortened esophagus within the chest, we believe better results can be achieved by an esophageal lengthening procedure with the wrap done intra-abdominally around the neoesophagus. Postoperative herniation can be prevented by narrowing the patulous esophageal hiatus and displacement of the wrap prevented by incorporating the superficial layers of the esophageal wall in the fundoplication sutures, deep suture placement being avoided to prevent development of leaks or fistulas or both.
2
3
4
5
6
7
8
REFERENCES Bombeck CT, Coelho RG, Castro VA, et al: An experimental comparison of procedures for the operative correction of gastroesophageal reflux. Bull Soc lot Chir 30:435-443, 1971 Leonardi HK, Lee ME, EI-Kurd MF, Ellis FH Jr: An experimental study of the effectiveness of various antireflux operations. Ann Thorac Surg 24:215-222, 1977 DeMeester TR, Johnson LF, Kent AH: Evaluation of current operations for the prevention of gastroesophageal reflux. Ann Surg 180:511-525, 1974 Nicholson DA, Nohl-Oser HC: Hiatus hernia. A comparison between two methods of fundoplication by evaluation of the long-term results. J THoRAc CARDIOVASC SURG 72:938-943, 1976 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 134:730-733, 1977 Hill LD, lives R, Stevenson JK, Persson JM: Reoperation for disruption and recurrence after Nissen fundoplication. Arch Surg 114:542-548, 1979 Rossman F, Brantigan CO, Sawyer RB: Obstructive complications of the Nissen fundoplication. Am J Surg 138:860-868, 1979 Henderson RD: Nissen hiatal hernia repair. Problems of
Thoracic and Cardiovascular Surgery
9
10
11 12
13
14 15 16
17
18 19
20
21
22
23
24
25
26
recurrence and continued symptoms. Ann Thorac Surg 28:587-593, 1979 Ellis FH Jr, Leonardi HK, Dabuzhsky L, Crozier RE: Surgery of short esophagus with stricture. An experimental and clinical manometric study. Ann Surg 188:341350, 1978 Ellis FH Jr, EI-Kurd MFA. Gibb SP: The effect of fundoplication on the lower esophageal sphincter. Surg Gynecol Obstet 143: 1-5, 1976 Ellis FH Jr: Gastroesophageal reflux. Indications for fundoplication. Surg Clin North Am 51:575-588, 1971 Ellis FH Jr, Garabedian M. Gibb SP: Fundoplication for gastroesophageal reflux. Indications, surgical technique, and manometric results. Arch Surg 107:186-192, 1973 Bahadorzadeh K, Jordan PH Jr: Evaluation of the Nissen fundoplication for treatment of hiatal hernia. Use of parietal cell vagotomy without drainage as an adjunctive procedure. Ann Surg 181:402-408, 1975 Menguy R: A modified fundoplication which preserves the ability to belch. Surgery 84:301-307, 1978 Rossetti M: Zur Technik der Fundoplication. Actuelle Chir 3:229-231, 1968 Cordiano C, Rovere GQD, Agugiaro S. Mazzilli G: Technical modification of the Nissen fundoplication procedure. Surg Gynecol Obstet 143:977-978, 1976 Polk HC Jr: Fundoplication for reflux esophagitis. Misadventures with the operation of choice. Ann Surg 183: 645-652. 1976 Olson RC, Lasser RB, Ansel H: The "slipped Nissen" (abstr). Gastroenterology 70:924, 1976 Safaie-Shirazi S, Zike WL, Mason EE: Esophageal stricture secondary to reflux esophagitis. Arch Surg 110:629631, 1975 Donahue PE, Bombeck CT: The modified Nissen fundoplication-reflux prevention without gas bloat. Chir Gastroenterol 11: 15-21, 1977 Bushkin FL, Neustein CL, Parker TH, Woodward ER: Nissen fundoplication for reflux peptic esophagitis. Ann Surg 185:672-677, 1977 Woodward ER. Thomas HF, McAlhany JC: Comparison of crural repair and Nissen fundoplication in the treatment of esophageal hiatus hernia with peptic esophagitis. Ann Surg 173:782-792, 1971 Ba1ison JR, Macgregor AM, Woodward ER: Postoperative diaphragmatic herniation following transthoracic fundopl ication. A note of warning. Arch Surg 106: 164166, 1973 Bremner CG: Gastric ulceration after a fundoplication operation for gastroesophageal reflux. Surg Gynecol Obstet 148:62-64, 1979 Ikard RW, Jacobs JK: Gastropericardial fistula and pericardia1 abscess. Unusual complications of subphrenic abscess following Nissen fundoplication. South Med J 67: 17-19, 1974 Burnett HF, Read RC, Morris WD, Campbell GS: Management of complications of fundoplication and Barrett's esophagus. Surgery 82:521-530, 1977
Volume 81
Nissen fundoplication
Number 1
January,
55
1981
27 Mullen JT, Burke EL, Diamond AB: Esophagogastric fistula. A complication of combined operations for esophageal disease. Arch Surg 110:826-828, 1975
Discussion DR. LUCIUS D. HILL Seattle. Wash.
This report covers a series similar to one that Dr. Riivo lives and I presented before the Western Surgical Association about a year ago. Although the classification that they used is different, the underlying disease is essentially the same. In our series of operations for recurrent hiatal hernias, which now numbers over 200 patients, the incompetent gastroesophageal junction was the most common cause of failure in all antireflux operations-the Nissen, the Allison, the Belsey, or whatever. We believe, and Dr. Leonardi indicates, that incompetence results from failure to calibrate the cardia at the time of the original operation. When left open, the cardia is incompetent and allows reflux. In our experience, the second most common problem is the slipped Nissen, followed by the disrupted, completely or partially, and the obstructed Nissen. The patulous or incompetent gastroesophageal junction accounted for seven of the authors' patients with recurrent reflux. As they indicate, not only were some of these junctions patulous or wide open at the original operation, but some had disrupted, either completely or partially, because the sutures had come out of the gastric wall. The slipped Nissen occurs because the sutures which should be at the gastroesophageal junction in the esophagus give way. The wraparound slips down and partially obstructs the upper part of the stomach. The authors indicated that several of their patients had had a motility disorder prior to operation. We have found this in a number of patients also and are being much more careful to look for the motility disorder prior to operating on these patients. Very simply, the obstructed Nissen results from wrapping the gastric fundus too tightly. This accounted for the "gas bloat" syndrome in their patients. They indicated that the wraparound was not only too tight but was also too long in four patients. We believe that this can be avoided by intraoperative pressure measurement at the time of operation, whether one is doing a posterior gastropexy or a Nissen procedure. If pressure is measured at operation, this should be an avoidable compl ication. Since our report a year ago, we have been inundated with a number of these complications and have accumulated an additional 28 patients. Among these cases we found gastrobronchial fistulas, esophagocutaneous fistulas, and gastrocutaneous fistulas. The mortality rate in these fistulas as reported around the world is 50%. This complication appears to be peculiar to the Nissen procedure. It does not occur with the posterior gastropexy or the Allison repair and has been reported infrequently with the Belsey. The sutures in the esophagus used to hold the Nissen wrap in place may pull out
and cause the fistulas. For this reason we avoid esophageal sutures in the posterior gastropexy. With telescoping of the esophagus in the Nissen operation, the patient has aperistalsis of the lower esophagus. The motility tracing shows absolutely no propulsive waves in the esophagus. Postoperatively, if the esophagus is put back on its normal tension, the abnormality in the lower esophageal sphincter is corrected. Again, we believe the motility disorder is a defect of the Nissen operation, particularly when the wraparound is allowed to wander back and forth through the hiatus. Cordiano in Italy and Kaminski in the United States both report that if they do not anchor the Nissen down, the esophageal motility is poor. Both Cordiano and Kaminski now anchor the wraparound to the preaortic fascia. The results in our original series were good. Redo failed Nissen operations are difficult, with few landmarks left at operation, particularly in a patient who has been operated upon two or three times. The bundles around the gastroesophageal junction are gone. In order to replace them we are using a Teflon collar that we place around the gastroesophageal junction and suture securely to the preaortic fascia. I note in the manuscript that Dr. Leonardi used our procedure in one patient. We have been able to convert the Nissen to the posterior gastropexy in all but two patients-one in whom a loss of continuity between the esophagus and stomach necessitated jejunal interposition and another in whom the esophagus was virtually destroyed and had to be replaced. We believe that, even in a patient who has been operated upon two or three times, it is better to rescue the esophagus than to replace it because of the long-term morbidity of the latter. I would like the authors to pay particular attention to the fact that it took us 9 years to accumulate 25 failed Nissen operations. Since our report before the Western Surgical Association (published in the Archives of Surgery), we have accumulated 28 more patients in I year. This is a mixed blessing. These patients are exceedingly difficult, but I do believe that with careful attention to detail the Nissen operation can be converted to a posterior gastropexy. We have been helped considerably by measuring the pressure during operation. Eight of the cases in the authors' series were their own recurrences. This indicates that even in the hands of expert surgeons the Nissen fails too often. It is time that we do better for the patient with a hiatus hernia. I note from the manuscript that the authors do very extensive preoperative and postoperative studies. I would ask them the question: Why not go ahead and measure the length and the strength of the sphincter at operation? DR.THOMASH. HOFFMANN San Antonio, Texas
I would like to congratulate the authors on an excellent presentation, especially since it confirms my prejudices regarding why the Nissen fundoplication sometimes fails. Louisville, Kentucky, has become a tertiary referral center
56
Leonardi, Crozier, Ellis
The Journal of Thoracic and Cardiovascular Surgery
for complicated or recurrent hiatal hernia, primarily because of the interest, expertise, and extensive writings of Dr. Hiram Polk. While I was in Louisville taking care of patients referred for reoperation, it became obvious to me that operative complications and recurrences were not inherent in the Nissen fundoplication itself, but rather were often secondary to technical error at the primary operation. This observation is illustrated by a case in which the Nissen fundoplication "slipped" down around the stomach. It is our opinion, contrary to the belief of the authors, that this case does represent an actual slippage of the fundoplication that could have been prevented by simple anchoring of the plication to the gastroesophageal junction with the lower two or three sutures of the fundoplication. A Nissen fundoplication that is loose enough to prevent gas bloat syndrome will be able to slide down onto the stomach unless it is anchored or otherwise suspended by the insertion of the left gastric artery. Gas bloat syndrome, fundoplication dehiscence, and hiatal hernia recurrence are likewise often due to technical errors at the initial operation. I would like to ask the authors if they routinely employ preoperative and intraoperative manometry for the evaluation of these patients. If so, has this improved the results? I would also like to stress several important points. First, hiatal herniation is primarily an anatomic abnormality which mayor may not require operation. An operation performed in cases in which the symptoms are minimal or in which the diagnosis is incorrect is associated with poor results. Second, the fundoplication must be of proper length, constructed without tension, and performed over a large bougie. We currently are using a No. 48 bougie and have had no problems with the wrap being too loose. Finally, the fundoplication should be anchored at the gastroesophageal junction with seromuscular sutures. DR. CHARLES O. BRANTIGAN Denver, Colo.
I would like to commend Dr. Leonardi on a superb presentation, which stressed the very simple principles that are important in preventing these sorts of complications of a Nissen fundoplication. Dr. Leonardi stressed not only the technical details but also the importance of preoperative manometry in evaluating these patients. I think these points are the keys to success. I would like to mention one type of obstructive complication that has not been mentioned so far-the herniation of the Nissen fundoplication through the diaphragm causing obstruction of the stomach. This is seen fairly commonly in Denver and it occurs because of failure to tighten the esophageal hiatus at the time of the repair. I would like to ask two questions: First, in the series of
patients whose work-up proved normal, that is, no anomalies were demonstrated, what were the indications in your series for reoperating upon these patients'? The second question concerns the use of fundoplication in patients with ineffective peristalsis. Some patients have esophageal spasm secondary to reflux esophagitis and eventually require operation. Our approach to these patients has been to perform a Nissen fundoplication using all of the principles that Dr. Leonardi has mentioned, and our results in four patients followed for I year postoperatively demonstrated return of effective peristalsis. Under what circumstances, Dr. Leonardi, do you use a fundoplication in patients with ineffective peristalsis and how can you distinguish the patients who will have return of normal esophageal motility from the patients who have a primary motility disturbance, who may have difficulty from just a fundoplication? DR. LEONARDI (Closing) I would like to thank the discussers for their comments. The question was asked if we always use preoperative manometry? The answer is "yes." Manometry is important not only in characterizing the lower esophageal sphincter but also in assessing the quality of esophageal motility. There are occasional cases in which significant underlying motility disorders occurring in the body of the esophagus require major modifications in the antireflux operation employed. The six patients in this series with esophageal aperistalsis emphasize the importance of preoperative manometry. Two of six patients did have severe reflux in the presence of esophageal aperistalsis and dearly needed a sphincterenhancing operation. The previously constructed fundoplication was converted to a Collis Belsey repair in each patient; this repair produced low-normal lower esophageal sphincteric pressure to allow for impaired esophageal motility. Intraoperative manometry has not been widely employed by us for the simple reason that we are uncertain how to interpret the results obtained on anesthetized patients. A question was asked concerning our indications for operating upon the six patients who had no manometric abnormality following fundoplication. In these patients the indication for operation was persistent and disabling dysphagia. We could only assume that the dysphagia was due to excessive tightness of the wrap, although we could not prove it by any investigative method that we employed. In closing, I would like to comment on the gas bloat syndrome, since it is usually emphasized in most discussions of post-fundoplication complications. In our experience, however, it is uncommon, and when it does occur it generally diminishes in severity with time. We strongly suspect that it is due to excessive tightness of the fundoplication , as were most of the complications that we discussed in our report.
THORAC CARDIOVASC SURG
81:50-56, 1981
Reoperation for complications of the Nissen fundoplication Case histories I~( 25 patients are reported ill whom complications after a Nissen fundoplication were sufficiently severe to require reopcration. Patients were classified by complications as having postoperative dvsphagia (14), recurrent reflux (.1'1'\'1'11), "Ras bloat' syndrome (two), and paraesophageal hernia (two). Six I~( the 14 patients with dysphagia had 110 esophageal peristalsis, 0111' had a panmural fibrous stricture, 0111' had a ' 'slipped" Nissen, and ill six the wrap lI'as presumed to IWI'e been fashioned too tight!v. Too tight a wrap was also responsible for the .1'£,\'1'11 instances ojrecurrent reflux and the two of ' 'gas bloat" syndrome. Revision of the fundoplication relieved the symptoms ill the 15 patients ill whom it was don l' . A variety I~( surgical procedures were performed Oil the other 10, all but 0111' o( whom experienced a Rood result, Proper selection ojpatientsjor operation coupled with attention to certain technical surgical details will ensure Rood results in 90'7c ofpatients after a Nissenfundoplication.
Howard K. Leonardi, M.D., Robert E, Crozier, M.D., and F. Henry Ellis, Jr., M.D., Ph.D" Burlington, Mass.
Antireflux operations are now widely employed for symptomatic relief of gastroesophageal reflux unresponsive to medical treatment. Differences of opinion exist, however, as to which sphincter-enhancing procedure is best. Although experimental': 2 and clinical":" studies suggest that the Nissen fundoplication is superior to the others in correcting reflux, it has been criticized by some as being unusually susceptible to postoperative complications, such as the "gas bloat" syndrome, dysphagia, recurrence of reflux, or displacement of the fundic wrap. 6-H This study was undertaken to classify these postfundoplication complications on the basis of our experience with patients requiring reoperation and to suggest means of minimizing their occurrence.
Patients and methods of analysis Twenty-five patients who had undergone a Nissen fundoplication required reoperation for a variety of From the Departments of Thoracic and Cardiovascular Surgery (Dr. Ellis) and Gastroenterology (Dr. Crozier), Lahey Clinic Medical Center, Overholt Thoracic Clinic (Dr. Leonardi), and Departments of Gastroenterology (Dr. Crozier) and Thoracic and Cardiovascular Surgery (Drs, Leonardi and Ellis), New England Deaconess Hospital, Boston, Mass, Read at the Sixth Annual Meeting of The Sampson Thoracic Surgical Society, Durango, Colo" June II to 14, 1980. Address for reprints: F, Henry Ellis, Jr., M.D,. Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, 41 Mall Rd., Burlington, Mass. 01803.
50
Table I. Complications of Nissen fundoplication requiring reoperation Dysphagia Aperistalsis Achalasia Diffuse esophageal spasm Scleroderma "Slipped" Nissen Peptic stricture Idiopathic Recurrent reflux "Gas bloat" syndrome Paraesophageal hernia Total
14 6
4 I
I I I 6
7
2 2 25
complications. Eight of the patients had been operated upon originally by us, and 17 patients had undergone operation elsewhere. The fundoplication had been performed between 3 and 38 months before reoperation, the postoperative interval averaging 16 months. Four of the 25 patients had had multiple previous operations on the esophagogastric junction totaling 12, including three Heller esophagomyotornies, two Allison hiatal hernia repairs, and seven Nissen fundoplications. The nature of the original antireflux operation was determined by careful scrutiny of the operative reports and by the findings at reoperation. Preoperative evaluation of the patient stressed esophageal manometry by techniques described elsewhere" as well as the usual roentgenographic and endoscopic studies. All patients
0022-5223/811010050+07$00.7010 © 1981 The C. V. Mosby Co.
Volume 81 Number 1 January, 1981
Nissen fundoplication
51
Table II. Manometric studies of lower esophageal sphincter Postoperative
Preoperative Category
No.*
Pressures (mm Hg)
Dysphagia Esophageal aperistalsis Idiopathic Miscellaneous Recurrent reflux "Gas bloat" Control Nissen Normal
6 6 2 7 2 38 14
20.0 15.0 16.0 6.3 16.5 16.1 12.7
I
Lengtht (em)
No.*
Pressuret (mm Hg)
3.5 3.2 3.5 3.3 6.5 4.4 3.5
5 6
11.0 15.0 15.0 20.4 13.0
I
6 2
I
Lengtht (em)
3.0 3.5 3.0 3.8 3.0
* Number of patients studied. t Recorded as mean values.
were available for follow-up analysis, which included clinical assessments in 25 patients, esophageal manometry in 20 patients, and barium contrast esophagography in 13 patients. The follow-up intervals varied from 3 months to 9 years, averaging 2.8 years. Classification of complications and results Although each patient requiring operation after a "failed" Nissen fundoplication presented certain unique problems not necessarily common to others, it was possible to classify the postoperative complications into general categories as listed in Table I. In Table II the preoperative and postoperative manometric findings are listed, as are those in normal individuals and those in patients after an uncomplicated Nissen fundoplication previously reported. 10 Dysphagia. Fourteen patients, seven of whom had no symptoms of dysphagia preoperatively, had severe dysphagia after fundoplication. Esophageal manometry disclosed no abnormalities of the lower esophageal sphincter (LES) but identified an underlying motility disorder characterized by aperistalsis of the esophagus in six patients. The motility pattern was diagnostic of achalasia in four patients, each of whom was initially operated upon for dysphagia incorrectly ascribed to distal esophageal narrowing by peptic stricture. A similar motility pattern was identified in a fifth patient in whom accompanying dermatologic findings suggested the diagnosis of scleroderma. Diffuse spasm of the distal half of the esophagus was manometrically evidenced in an additional patient. A "slipped" Nissen was suspected in one patient in whom two distinct distal high-pressure zones were discernible, and in another patient dysphagia was caused by severe narrowing of the distal esophagus by a long peptic stricture. The cause of dysphagia was categorized as idiopathic in the remaining six patients because
no abnormalities could be identified preoperatively by esophageal manometry, endoscopy, or roentgenography, and repeated dilations were ineffective. The corrective procedure was individualized in each patient and was most complex in the subset of patients with esophageal aperistalsis. In this subset reoperations included takedown of the previous Nissen in two patients, conversion to a Collis-Belsey repair in two patients, total esophagectomy with colon interposition in one patient, and a long esophagomyotomy in one patient. An additional patient with a severe peptic stricture required an esophagogastrectomy for relief of dysphagia. In the remaining seven patients, revision of the previous Nissen fundoplication was performed. Thirteen of 14 patients reported satisfactory relief of dysphagia, and one patient with advanced scleroderma had mild residual symptoms of dysphagia. An analysis of manometric data within the category of patients with dysphagia disclosed differences between preoperative and postoperative LES characteristics only within the esophageal aperistalsis group, in whom postoperative LES pressures were lower. Recurrent reflux. Symptoms of recurrent reflux occurred in seven patients after fundoplication at intervals of 4 to 36 months, averaging 19 months. Preoperative manometry disclosed hypotensive LES pressures in all patients, with values ranging from 3 to 10 mm Hg and averaging 6.3 mm Hg (Table II). At reoperation, complete disruption of the fundoplication was evident in five patients, and partial disruption, resulting in a less than circumferential wrap, had occurred in two. Reconstruction of a circumferential wrap was performed in each patient. All patients reported relief of reflux symptoms postoperatively, and mean postoperative LES pressures were increased approximately threefold over preoperative values. "Gas bloat" syndrome. "Gas bloat" syndrome
52
The Journal of Thoracic and Cardiovascular Surgery
Leonardi, Crozier, Ellis
serious enough to require reoperation occurred in two patients 8 months and 12 months after Nissen fundoplication. Both patients had experienced satisfactory relief of previously intractable reflux symptoms but had complained repeatedly of an inability to belch. Although motility studies disclosed normal LES pressures in both patients, the high-pressure zone in one patient extended over a longer length of distal esophagus than we consider optimal (7 em as opposed to 3 to 5 em). In this patient, the wrap was revised so as to include only the distal 3 em of esophagus. In the second patient, the Nissen fundoplication was converted to a Hill posterior gastropexy. Both patients reported relief of their disturbing preoperative symptoms after these revisions. Postoperative manometry disclosed normal LES pressures while LES length had been reduced by more than one half when compared with the preoperative length (Table II). ParaesophageaI hernia. Paraesophageal hernia developed in two patients at intervals of 2 years and 3 years after fundoplication. One patient who was asymptomatic was recommended for operation in view of the risk of serious sequelae should strangulation of the herniated distal stomach occur. The second patient reported intermittent epigastric and retrosternal discomfort and occasional nausea without vomiting for several weeks. Neither patient had experienced symptoms of recurrent reflux, and motility studies were not performed. Transabdominal reduction of the herniated stomach and retroesophageal suture narrowing of the diaphragmatic crura were performed successfully in both patients with relief of symptoms.
Surgical technique Although the technical details of the performance of a Nissen fundoplication have been published extensively by US 1l1- 12 elsewhere and will not be reviewed in detail here, several aspects of the procedure merit reemphasis. Adequate transabdominal mobilization of the distal 5 to 7 em of esophagus without vagal injury is essential for proper location of the fundic wrap. The mobilized esophagus is encircled by an elasticized tape and held in gentle inferior traction while a fundic wrapping maneuver without tension is facilitated by division of several of the uppermost short gastric vessels as well as the gastrohepatic ligament. An intraluminal stent of adequate caliber (our preference is a No. 40 Fr. mercury-filled bougie) is essential for avoidance of an unduly tight wrap. Inferior displacement of the wrap is discouraged by including esophageal musculature between the sero-
muscular gastric sutures. Further stabilization of the wrap is achieved by placing sutures between the superior rim of the wrap and esophageal muscle circumferentially. A crural repair with heavy, nonabsorbable sutures should also be performed if the esophageal hiatus admits more than the tips of two fingers. Nasogastric suction is not routinely employed in the postoperative period but may be of value in some instances to avoid gastric distention, which may threaten the integrity of the newly constructed fundoplication. Adherence to these principles, coupled with proper patient selection, should lead to gratifying results in the majority of patients. This at least has been our experience with 77 fundoplication procedures including the 15 Nissen revisions reported here. Symptomatic reflux has been relieved completely and permanently in all but four patients (95%) over a follow-up period averaging 4.2 years. Four other patients had unsatisfactory results, for an overall success rate of 90%.
Discussion The introduction of new surgical procedures is usually accompanied by a period of experimentation in which the originally described technique undergoes modifications before it is ultimately standardized into a procedure that can give predictably good results. The Nissen fundoplication is no exception, for the 360 degree wrap of the distal esophagus with anterior and posterior walls of the adjacent gastric fundus has undergone a number of modifications, including the incorporation of highly selective vagotomy, 1:1 wrapping of less than 360 degrees of the stomach, I~ use of the anterior gastric wall alone, I:; and the employment of posterior gastropexy in association with fundoplication.!" These many modifications make it difficult at reoperation to determine what actually was performed at the first procedure and emphasizes the need for standardization of the operation if good results are to be uniformly achieved. Evidence for this is provided by the fact that we have had to reoperate upon 25 patients, some of them our own, who had had an unsuccessful "Nissen" operation. The complications leading to reoperation in this series have been classified on the basis of symptoms, in the hope thereby to obtain insights into the causes of failure and clues as to their avoidance. Reoperation was necessitated in more than half of the patients by postoperative dysphagia. Transient dysphagia beginning between the seventh and the tenth postoperative days is a well-recognized phenomenon, presumably resulting from postoperative edema, 10. 17 but rarely proves to be
Volume 81 Number 1 January, 1981
a significant clinical problem. The dysphagia experienced by the patients requiring reoperation was persistent. Its main cause was improper application of an antireflux procedure to patients with absence of peristalsis in the body of the esophagus. The importance of adequate preoperative assessment of the patient about to undergo an antireflux maneuver, particularly with regard to esophageal motility, cannot be overemphasized. The term "slipped" Nissen has been adopted widely since its introduction to describe cases in which the wrap surrounds gastric corpus rather than distal esophagus.!" We suspect it usually occurs, as it did in one of our patients, because of inadequate mobilization of the distal esophagus with performance of the wrap around the stomach itself rather than by slippage of the wrap from esophagus above to stomach below. Whatever the cause, it leads to obstructive symptoms, which can be relieved only by repositioning the wrap in its proper location. Although some have advocated performing a Nissen fundoplication around a fibrous stricture;'? we have found that, at least in instances of firm panmural fibrosis, such a procedure is ineffective, as it was in one of our patients. Currently, we prefer to employ a Collis gastroplasty so that the Nissen fundal wrap can be fashioned around pliable, healthy tissue. Adequate control of reflux and effective dilation of the stricture are thereby ensured." Six of the patients with persistent postoperative dysphagia as a cause for reoperation did not have this symptom preoperatively, and careful postoperative assessment including endoscopy, esophageal manometry, and radioscopic examination of the upper gastrointestinal tract failed to reveal the cause of this persistent and disabling symptom. We assume that the original wrap was fashioned too tightly in these individuals, but current investigative techniques are not sophisticated enough to measure this variable. Symptoms were relieved in these patients by taking down the original wrap and refashioning it more loosely. The importance of a loose wrap in avoiding complications has convincing experimental support. 20 Too tight a wrap may predispose to breakdown of the fundoplication and recurrent reflux, a complication that occurs in about 10% of patients in some series. 14. 21 Although such breakdowns usually appear within the first postoperative year, 17 one of the recurrences we are reporting did not occur until 3 years after operation. In all seven of our patients with reflux as a cause of reoperation, the previously placed sutures were found to have pulled through the gastric wall. The LES pres-
Nissen fundoplication
53
sures were in the hypotensive range preoperatively in all and were restored to high normal levels by revision of the fundoplication with relief of symptoms. Although persistent postoperative reflux may be the result of too loose a wrap," we encountered no such case in this series, probably because we have avoided the use of too large a stent. Too tight a wrap is probably also responsible for the "gas bloat" syndrome, which occurred in as many as 54% of Woodwards'" original series, although with further follow-up review the incidence was reduced to 13%.21 In our!" experience and that of others ,!? this complication has been rare. The only manometric abnormality identifiable in our two patients was an excessively long wrap in one. Both were relieved of symptoms by revision of the fundoplication. Experience with another patient not requiring reoperation suggests that another cause may be placement of the fundoplication within the chest, with obstruction developing at the diaphragmatic level. Although we originally had considered intrathoracic fundoplication as a reasonable undertaking in patients with a shortened esophagus, experience with this patient has led us to perform a Collis gastroplasty as an esophageal lengthening procedure in such instances; we fashion the Nissen wrap around the neoesophagus in the abdomen, rather than resorting to an intrathoracic fundoplication. The need for adequate narrowing of the patulous hiatus in patients with reflux and a hiatus hernia undergoing a Nissen procedure is emphasized by two of our patients in whom a postoperative hernia developed, a complication previously described.F These patients experienced the usual postprandial symptoms of a paraesophageal hernia, which were relieved by reduction of the hernia and adequate narrowing of the esophageal hiatus. Other complications have been described, such as gastric ulceration;" gastric leaks resulting in peritonitis with fistulous communication with other viscera (bronchus or pericardium), 6. 25. 26 and esophagogastric fistulas between the fundoplication and adjacent esophagus." Such complications, which we fortunately did not encounter, probably are due to impairment of the blood supply of the gastric fundus and to the placement of deep necrosing sutures in the esophagus. The growing list of postfundoplication complications suggests that insufficient emphasis has been placed on the technical details that make the Nissen fundoplication both safe and effective. We still believe that, when properly performed, the 360 degree wrap of the distal
The Journal of
54
Leonardi, Crozier, Ellis
3.5 to 5 em of esophagus by adjacent gastric fundus (classic Nissen operation) is the preferred method of treatment of symptomatic gastroesophageal reflux resistant to medical therapy. For it to be successful, however, certain precautions are essential. Accurate preoperative diagnosis is necessary to avoid its performance on the aperistaltic esophagus. Also to be avoided are patients with hard panmural fibrous strictures, in whom the compressive effect of the Nissen wrap has proved to be ineffective. The wrap should be performed over a large-bore (No. 40 Fr.) tube to prevent overzealous tightening, which might result in postoperative dysphagia, the "gas bloat" syndrome, or breakdown of the wrap with recurrent reflux. Although some prefer a larger stent, the risk of persistent reflux might thereby be increased. Rather than fashion the fundoplication around a shortened esophagus within the chest, we believe better results can be achieved by an esophageal lengthening procedure with the wrap done intra-abdominally around the neoesophagus. Postoperative herniation can be prevented by narrowing the patulous esophageal hiatus and displacement of the wrap prevented by incorporating the superficial layers of the esophageal wall in the fundoplication sutures, deep suture placement being avoided to prevent development of leaks or fistulas or both.
2
3
4
5
6
7
8
REFERENCES Bombeck CT, Coelho RG, Castro VA, et al: An experimental comparison of procedures for the operative correction of gastroesophageal reflux. Bull Soc lot Chir 30:435-443, 1971 Leonardi HK, Lee ME, EI-Kurd MF, Ellis FH Jr: An experimental study of the effectiveness of various antireflux operations. Ann Thorac Surg 24:215-222, 1977 DeMeester TR, Johnson LF, Kent AH: Evaluation of current operations for the prevention of gastroesophageal reflux. Ann Surg 180:511-525, 1974 Nicholson DA, Nohl-Oser HC: Hiatus hernia. A comparison between two methods of fundoplication by evaluation of the long-term results. J THoRAc CARDIOVASC SURG 72:938-943, 1976 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 134:730-733, 1977 Hill LD, lives R, Stevenson JK, Persson JM: Reoperation for disruption and recurrence after Nissen fundoplication. Arch Surg 114:542-548, 1979 Rossman F, Brantigan CO, Sawyer RB: Obstructive complications of the Nissen fundoplication. Am J Surg 138:860-868, 1979 Henderson RD: Nissen hiatal hernia repair. Problems of
Thoracic and Cardiovascular Surgery
9
10
11 12
13
14 15 16
17
18 19
20
21
22
23
24
25
26
recurrence and continued symptoms. Ann Thorac Surg 28:587-593, 1979 Ellis FH Jr, Leonardi HK, Dabuzhsky L, Crozier RE: Surgery of short esophagus with stricture. An experimental and clinical manometric study. Ann Surg 188:341350, 1978 Ellis FH Jr, EI-Kurd MFA. Gibb SP: The effect of fundoplication on the lower esophageal sphincter. Surg Gynecol Obstet 143: 1-5, 1976 Ellis FH Jr: Gastroesophageal reflux. Indications for fundoplication. Surg Clin North Am 51:575-588, 1971 Ellis FH Jr, Garabedian M. Gibb SP: Fundoplication for gastroesophageal reflux. Indications, surgical technique, and manometric results. Arch Surg 107:186-192, 1973 Bahadorzadeh K, Jordan PH Jr: Evaluation of the Nissen fundoplication for treatment of hiatal hernia. Use of parietal cell vagotomy without drainage as an adjunctive procedure. Ann Surg 181:402-408, 1975 Menguy R: A modified fundoplication which preserves the ability to belch. Surgery 84:301-307, 1978 Rossetti M: Zur Technik der Fundoplication. Actuelle Chir 3:229-231, 1968 Cordiano C, Rovere GQD, Agugiaro S. Mazzilli G: Technical modification of the Nissen fundoplication procedure. Surg Gynecol Obstet 143:977-978, 1976 Polk HC Jr: Fundoplication for reflux esophagitis. Misadventures with the operation of choice. Ann Surg 183: 645-652. 1976 Olson RC, Lasser RB, Ansel H: The "slipped Nissen" (abstr). Gastroenterology 70:924, 1976 Safaie-Shirazi S, Zike WL, Mason EE: Esophageal stricture secondary to reflux esophagitis. Arch Surg 110:629631, 1975 Donahue PE, Bombeck CT: The modified Nissen fundoplication-reflux prevention without gas bloat. Chir Gastroenterol 11: 15-21, 1977 Bushkin FL, Neustein CL, Parker TH, Woodward ER: Nissen fundoplication for reflux peptic esophagitis. Ann Surg 185:672-677, 1977 Woodward ER. Thomas HF, McAlhany JC: Comparison of crural repair and Nissen fundoplication in the treatment of esophageal hiatus hernia with peptic esophagitis. Ann Surg 173:782-792, 1971 Ba1ison JR, Macgregor AM, Woodward ER: Postoperative diaphragmatic herniation following transthoracic fundopl ication. A note of warning. Arch Surg 106: 164166, 1973 Bremner CG: Gastric ulceration after a fundoplication operation for gastroesophageal reflux. Surg Gynecol Obstet 148:62-64, 1979 Ikard RW, Jacobs JK: Gastropericardial fistula and pericardia1 abscess. Unusual complications of subphrenic abscess following Nissen fundoplication. South Med J 67: 17-19, 1974 Burnett HF, Read RC, Morris WD, Campbell GS: Management of complications of fundoplication and Barrett's esophagus. Surgery 82:521-530, 1977
Volume 81
Nissen fundoplication
Number 1
January,
55
1981
27 Mullen JT, Burke EL, Diamond AB: Esophagogastric fistula. A complication of combined operations for esophageal disease. Arch Surg 110:826-828, 1975
Discussion DR. LUCIUS D. HILL Seattle. Wash.
This report covers a series similar to one that Dr. Riivo lives and I presented before the Western Surgical Association about a year ago. Although the classification that they used is different, the underlying disease is essentially the same. In our series of operations for recurrent hiatal hernias, which now numbers over 200 patients, the incompetent gastroesophageal junction was the most common cause of failure in all antireflux operations-the Nissen, the Allison, the Belsey, or whatever. We believe, and Dr. Leonardi indicates, that incompetence results from failure to calibrate the cardia at the time of the original operation. When left open, the cardia is incompetent and allows reflux. In our experience, the second most common problem is the slipped Nissen, followed by the disrupted, completely or partially, and the obstructed Nissen. The patulous or incompetent gastroesophageal junction accounted for seven of the authors' patients with recurrent reflux. As they indicate, not only were some of these junctions patulous or wide open at the original operation, but some had disrupted, either completely or partially, because the sutures had come out of the gastric wall. The slipped Nissen occurs because the sutures which should be at the gastroesophageal junction in the esophagus give way. The wraparound slips down and partially obstructs the upper part of the stomach. The authors indicated that several of their patients had had a motility disorder prior to operation. We have found this in a number of patients also and are being much more careful to look for the motility disorder prior to operating on these patients. Very simply, the obstructed Nissen results from wrapping the gastric fundus too tightly. This accounted for the "gas bloat" syndrome in their patients. They indicated that the wraparound was not only too tight but was also too long in four patients. We believe that this can be avoided by intraoperative pressure measurement at the time of operation, whether one is doing a posterior gastropexy or a Nissen procedure. If pressure is measured at operation, this should be an avoidable compl ication. Since our report a year ago, we have been inundated with a number of these complications and have accumulated an additional 28 patients. Among these cases we found gastrobronchial fistulas, esophagocutaneous fistulas, and gastrocutaneous fistulas. The mortality rate in these fistulas as reported around the world is 50%. This complication appears to be peculiar to the Nissen procedure. It does not occur with the posterior gastropexy or the Allison repair and has been reported infrequently with the Belsey. The sutures in the esophagus used to hold the Nissen wrap in place may pull out
and cause the fistulas. For this reason we avoid esophageal sutures in the posterior gastropexy. With telescoping of the esophagus in the Nissen operation, the patient has aperistalsis of the lower esophagus. The motility tracing shows absolutely no propulsive waves in the esophagus. Postoperatively, if the esophagus is put back on its normal tension, the abnormality in the lower esophageal sphincter is corrected. Again, we believe the motility disorder is a defect of the Nissen operation, particularly when the wraparound is allowed to wander back and forth through the hiatus. Cordiano in Italy and Kaminski in the United States both report that if they do not anchor the Nissen down, the esophageal motility is poor. Both Cordiano and Kaminski now anchor the wraparound to the preaortic fascia. The results in our original series were good. Redo failed Nissen operations are difficult, with few landmarks left at operation, particularly in a patient who has been operated upon two or three times. The bundles around the gastroesophageal junction are gone. In order to replace them we are using a Teflon collar that we place around the gastroesophageal junction and suture securely to the preaortic fascia. I note in the manuscript that Dr. Leonardi used our procedure in one patient. We have been able to convert the Nissen to the posterior gastropexy in all but two patients-one in whom a loss of continuity between the esophagus and stomach necessitated jejunal interposition and another in whom the esophagus was virtually destroyed and had to be replaced. We believe that, even in a patient who has been operated upon two or three times, it is better to rescue the esophagus than to replace it because of the long-term morbidity of the latter. I would like the authors to pay particular attention to the fact that it took us 9 years to accumulate 25 failed Nissen operations. Since our report before the Western Surgical Association (published in the Archives of Surgery), we have accumulated 28 more patients in I year. This is a mixed blessing. These patients are exceedingly difficult, but I do believe that with careful attention to detail the Nissen operation can be converted to a posterior gastropexy. We have been helped considerably by measuring the pressure during operation. Eight of the cases in the authors' series were their own recurrences. This indicates that even in the hands of expert surgeons the Nissen fails too often. It is time that we do better for the patient with a hiatus hernia. I note from the manuscript that the authors do very extensive preoperative and postoperative studies. I would ask them the question: Why not go ahead and measure the length and the strength of the sphincter at operation? DR.THOMASH. HOFFMANN San Antonio, Texas
I would like to congratulate the authors on an excellent presentation, especially since it confirms my prejudices regarding why the Nissen fundoplication sometimes fails. Louisville, Kentucky, has become a tertiary referral center
56
Leonardi, Crozier, Ellis
The Journal of Thoracic and Cardiovascular Surgery
for complicated or recurrent hiatal hernia, primarily because of the interest, expertise, and extensive writings of Dr. Hiram Polk. While I was in Louisville taking care of patients referred for reoperation, it became obvious to me that operative complications and recurrences were not inherent in the Nissen fundoplication itself, but rather were often secondary to technical error at the primary operation. This observation is illustrated by a case in which the Nissen fundoplication "slipped" down around the stomach. It is our opinion, contrary to the belief of the authors, that this case does represent an actual slippage of the fundoplication that could have been prevented by simple anchoring of the plication to the gastroesophageal junction with the lower two or three sutures of the fundoplication. A Nissen fundoplication that is loose enough to prevent gas bloat syndrome will be able to slide down onto the stomach unless it is anchored or otherwise suspended by the insertion of the left gastric artery. Gas bloat syndrome, fundoplication dehiscence, and hiatal hernia recurrence are likewise often due to technical errors at the initial operation. I would like to ask the authors if they routinely employ preoperative and intraoperative manometry for the evaluation of these patients. If so, has this improved the results? I would also like to stress several important points. First, hiatal herniation is primarily an anatomic abnormality which mayor may not require operation. An operation performed in cases in which the symptoms are minimal or in which the diagnosis is incorrect is associated with poor results. Second, the fundoplication must be of proper length, constructed without tension, and performed over a large bougie. We currently are using a No. 48 bougie and have had no problems with the wrap being too loose. Finally, the fundoplication should be anchored at the gastroesophageal junction with seromuscular sutures. DR. CHARLES O. BRANTIGAN Denver, Colo.
I would like to commend Dr. Leonardi on a superb presentation, which stressed the very simple principles that are important in preventing these sorts of complications of a Nissen fundoplication. Dr. Leonardi stressed not only the technical details but also the importance of preoperative manometry in evaluating these patients. I think these points are the keys to success. I would like to mention one type of obstructive complication that has not been mentioned so far-the herniation of the Nissen fundoplication through the diaphragm causing obstruction of the stomach. This is seen fairly commonly in Denver and it occurs because of failure to tighten the esophageal hiatus at the time of the repair. I would like to ask two questions: First, in the series of
patients whose work-up proved normal, that is, no anomalies were demonstrated, what were the indications in your series for reoperating upon these patients'? The second question concerns the use of fundoplication in patients with ineffective peristalsis. Some patients have esophageal spasm secondary to reflux esophagitis and eventually require operation. Our approach to these patients has been to perform a Nissen fundoplication using all of the principles that Dr. Leonardi has mentioned, and our results in four patients followed for I year postoperatively demonstrated return of effective peristalsis. Under what circumstances, Dr. Leonardi, do you use a fundoplication in patients with ineffective peristalsis and how can you distinguish the patients who will have return of normal esophageal motility from the patients who have a primary motility disturbance, who may have difficulty from just a fundoplication? DR. LEONARDI (Closing) I would like to thank the discussers for their comments. The question was asked if we always use preoperative manometry? The answer is "yes." Manometry is important not only in characterizing the lower esophageal sphincter but also in assessing the quality of esophageal motility. There are occasional cases in which significant underlying motility disorders occurring in the body of the esophagus require major modifications in the antireflux operation employed. The six patients in this series with esophageal aperistalsis emphasize the importance of preoperative manometry. Two of six patients did have severe reflux in the presence of esophageal aperistalsis and dearly needed a sphincterenhancing operation. The previously constructed fundoplication was converted to a Collis Belsey repair in each patient; this repair produced low-normal lower esophageal sphincteric pressure to allow for impaired esophageal motility. Intraoperative manometry has not been widely employed by us for the simple reason that we are uncertain how to interpret the results obtained on anesthetized patients. A question was asked concerning our indications for operating upon the six patients who had no manometric abnormality following fundoplication. In these patients the indication for operation was persistent and disabling dysphagia. We could only assume that the dysphagia was due to excessive tightness of the wrap, although we could not prove it by any investigative method that we employed. In closing, I would like to comment on the gas bloat syndrome, since it is usually emphasized in most discussions of post-fundoplication complications. In our experience, however, it is uncommon, and when it does occur it generally diminishes in severity with time. We strongly suspect that it is due to excessive tightness of the fundoplication , as were most of the complications that we discussed in our report.