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Evaluation and Treatment of Postfundoplication Problems
John M. Wo, M.D.
3/4/2015
IDI Indiana University Health
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Evaluation and Treatment of Postfundoplication Problems
• Case study
• Key steps in evaluating postfundoplication problems
• Treatment and expectation
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Case #1
• 34 yo female c/o debilitating bloating after antireflux surgery
• Pre-op - Chronic typical heartburn
• S/p lap Nissen fundoplication 11 months ago
• Post-op
- Heartburn resolved but developed new postprandial bloating and nausea
- Report mild, infrequent dysphagia IOI 111 I SCHOOL OF MEDICINE Indiana University Health · INDIA NA U IVERSITY
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Case # 1 (cont.)
• Pre-op manometry - LES 20 mmHg, distal esophageal P 44 mmHg,
- 100% peristalsis
• Pre-op pH test - Distal esophageal acid time pH<4: 10%
- Proximal esophageal acid time pH<4: 3.8%
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Case # 1 (cont.)
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Case # 1 (cont.)
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Case # 1 (cont.)
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Case # 1 (cont.)
• EGD - Slightly slipped otherwise normal
- Dilated to 60 F
• No improvement in bloating
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Case # 1 (cont.) • 4-hr GET
- 10% residual at 2 hrs
- 0% residual at 4 hrs
• Repeat esophageal manometry & pH test normal
• Dilated with 3 cm achalasia balloon did not help
• Repeat 4-hr GET normal
• Small bowel manometry normal
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Case # 1 (cont.)
• Diagnosis - "Functional" postfundoplication gas-bloat
- Esophageal or gastric function normal
• Underwent re-do surgery - Conversion to Toupet (partial) fundoplication
• Symptoms improved 25%
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Nissen (360°) Fundoplication
Indiana University Health
Esophag~ • Avoid esophageal tension
Diap~rag~ • Take down short
Fundus
Stomach
gastric vessels to mobilize fundus
• 2 cm fundus wrap over 54-60 F dilator
• Close crura defect
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Key Factors for Successful Antireflux Surgery
• Proper patient selection
• Pre-operative evaluation
• Surgical technique
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Key Steps in Evaluating Postfundo.Qlication Problems
1) What are the pre-op symptoms?
2) Are the post-op symptoms new, old, or both?
3) Review pre-op testing
4) Correlate post-op anatomy & physiology
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Step 1 :What are the Pre-op Symptoms?
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Symptoms Requiring Fundoplication
• Typical heartburn and regurgitation
• Atypical GERD
- Chest pain, asthma, epigastric burning, etc.
• Additional symptoms besides GERD
- "Red flags?"
• Wrong diagnosis
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Fundoplication: Efficacy in Relieving TY.12ical Heartburn
*Follow-up from 6 to 15 months.
Allen et al. Thorax. 1998;53:963-968. Campos et al. J Gastrointest Surg. 1999;3:292-300.
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Hunter et al. Ann Surg. 1996;223:673-685. So et al. Surgery. 1998;124:28-32.
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Long-Term Follow-Up of Medication Use After Fundoplication
100
80 .-. ';fl ..._.. tn .... 60 c CD ·-.... ca 40
D..
20
0
11 to 13 years f/u.
92
62
Currently Taking Any Antireflux Medication
Spechler et al. JAMA. 2001 ;285:2331-2338.
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D Originally Received Medical Therapy (n = 166)
64 D Original Surgica
ly Received I Therapy (n = 82)
32
Currently Taking PPI Therapy
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Fundoplication: Efficacy in Relief of Atypical GERD
N = 150 (35 with atypical symptoms). So et al. Surgery. 1998; 124:28-32.
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Pre-op "Red Flags" for Fundoplication
• No response to PPI
- Wrong diagnosis, achalasia, gastroparesis
• NERD, chest pain
- Hypersensitive esophagus, spasm
• Large hiatal hernia, dysphagia, or multiple dilations
- Shortened esophagus
• Nausea, vomiting & bloating
- Gastroparesis, aerophagia
• Pre-op impaired esophageal motility
- Increase postfundoplication dysphagia
• IBS, depression, anxiety, etc.
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Step 2: Are the Post-op Symptoms New, Old, or Both?
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Postfundoplication Symptoms
• Recurrence of pre-op symptoms
• New post-op symptoms - Dysphagia - Gas-bloat - Chest pain - Epigastric/ Abdominal pain - Diarrhea - Increased flatus
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Causes of Postfundoplication Problems
Recurrent Symptoms
• Loosen or disrupted wrap
• Wrong diagnosis
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New Symptoms
• Slipped fundoplication
• Paraesophageal hernia
• Gastroparesis & vagal neuropathy
• Functional bloating (air trapping)
• Too tight
• Esophagealspasm
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Step 3: Review Pre-op Testing
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Pre-op Evaluation for Antireflux Surgery
• EGD
• Esophageal manometry
• pH test in patients without esophagitis
• Gastric emptying in selected patients
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Step 4: Correlate Post-op Anatomy & Physiology
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Anatomic Consideration
• Wrap integrity - 1) Normal (intact)
- 2) Loosen (disrupted)
- 3) Too tight (too long)
- 4) Slipped wrap
- 5) Paraesophageal herniation
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A
Normal Wrap
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A
Loosen Wrap
A
Slipped Wrap
TIT ~_SC_H_O_O_L_O_F_M_E_D_I_C_I_N_E 'I' I ND IANA U I VERS I TY
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Fundoplication Anatomy
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Type 1A:
- Herniation of the fundoplication into the chest.
- Usually results from disruption of the crural . repair
Type 18:
- Part of the stomach lies both above and below the wrap.
- Stomach slips through the fundoplication
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Fundoplication Anatomy
Type II Type Ill
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Type II:
-Development of a paraesophageal hernia
Type Ill:
- Malposition of the wrap leading to a two -compartment stomach
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Slipped Wrap
Esophageal tension Potential Risk Factors
• Large hiatal and paraesophageal hernia
• Scarred esophagus
• Barrett's esophagus
• Inadequate surgical exposure
• Retching and vomiting
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Type 1 Sliding hernia
Type2 True
Paraesophageal hernia
lnl Wo JM et al. Am J Gastroenterol 1996;91 :914-916.
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Type3 Mixed
Paraesophageal hernia
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Physiologic Consideration
• Esophageal peristalsis - Manometry
• Impaired or Absent (achalasia or secondary from GERO or wrap)
• Esophageal transit - Timed barium swallow (Achalasia protocol)
• Gastroparesis - Gastric scintigraphy
• Vagal neuropathy - Antroduodenal manometry
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Postfundoplication Testing Protocol
1. Esophageal manometry
2. EGD
3. 4-hr GET
• Others, depending on clinical scenario - Barium swallow - Timed barium swallow - Bravo pH - Small bowel manometry IOI Indiana University Health
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Normal Wrap
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Barium Tablet Impaction is Common After Antireflux Surge!"1
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Tight or Long Wrap
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Slipped Wrap & GEJ Stricture
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Slipped Fundoplication
Wrap
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Very Slipped Wrap
~ GEJ
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Slipped Wrap
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Paraesophageal Hernia
GEJ
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Paraesophageal Hernia
GEJ
Wrap
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Paraesophageal Hernia
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Gastric Mucosa Adjacent to Wrap
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EGD for Postfundoplication Evaluation
• Antegrade view
• Retrograde view
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EGD: Antegrade View
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Slightly Slipped Wrap
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Slightly Slipped Wrap
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OK but Slightly Slipped Wrap
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Slipped Wrap
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Postfundo Reflux Stricture
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EGD: Retrograde View
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Retrograde View: Normal Wrap
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Retrograde View: Small Opening Adjacent to Wrap
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Retrograde View: Medium Opening Adjacent to Wrap
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Retrograde View: Large Opening Adjacent to Wrap
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Wrap Too Long
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Loose Wrap
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Loose Wrap
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Total Disrupted Wrap
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"Double Whammy" : Slipped Wrap+ Paraesophageal Hernia
Wrap involving proximal stomach
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Opening next to
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"Triple Whammy" : Slipped + Paraesophageal Hernia + Loose
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Stomach
wrap: slipped
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Postfundoplication Syndromes
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Postfundoplication Dysphagia
• Transient dysphagia: 60%
• Dysphagia requiring dilation: 6-13%
Hunter et al. Ann Surg. 1996;223:673-685. Malhi-Chawla et al. Gastrointest Endosc. 2002;55:219-
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Causes of Postfundoplication Dysphagia
Early post-op Late post-op
• Edema • Slipped wrap
• Wrap too tight • Paraesophageal hernia
• Esophageal stricture • Esophageal stricture
• Unrecognized achalasia
• Esophagealspasm
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Postfundoplication Dysphagia and Esophageal Dilatation
• No Dilatation • Dysphagia Resolved
• Lost to Follow-Up • Dysphagia Persisted
• Dilatation for Other Complaints
5°/o \ \
'* ' 87o/o I 12% 3°/o I I
I
4°/o
N = 233. Malhi-Chawla et al. Gastrointest Endosc. 2002;55:219-223.
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Endoscopic Management of Postfundoplication Dysphagia
• Dilation is safe but effective in only 50% of patients
• Predictors of poor outcome - Slipped wrap
- No response to dilation
- Multiple fundoplications
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Postfundoplication Gas Bloat
• Approx. 20% unable to belching
• 5 to 20% gas-bloat syndrome
• May require re-operation
Hunter et al. Ann Surg. 1996;223:673-685. llidell et a. J Am Col Surg 2001 ;192:172-179. a Indiana University Health
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Causes of Postfundoplication Gas-Bloat
• Aerophagia
• Slipped fundoplication
• Gastroparesis - Pre-op condition
- Post-surgical vagal neuropathy
• "Functional"
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Diarrhea I Flatulence
40% o Preopera \re • Postoperative
30%
20%
10%
Diarrhea. 8~aafing1 Constipation Abdominal F'aln
• 15 (18%) patients reported new-onset diarrhea
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Conclusions
• Key steps in evaluating postfundoplication problems 1) What are the pre-op symptoms?
2) Are the post-op complaints new, old, or both?
3) Review pre-op testing
4) Correlate post-op anatomy & physiology
• Abnormal anatomy may not be causing symptoms
• Treatment is suboptimal
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