Treating Complications Dysphagia, Leaks, Gastric Dysfunction Following Nissen Fundoplication Brant...
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![Page 1: Treating Complications Dysphagia, Leaks, Gastric Dysfunction Following Nissen Fundoplication Brant K. Oelschlager, MD University of Washington.](https://reader035.fdocuments.in/reader035/viewer/2022062314/56649ec65503460f94bd1f4c/html5/thumbnails/1.jpg)
Treating Complications
Dysphagia, Leaks, Gastric DysfunctionFollowing Nissen Fundoplication
Brant K. Oelschlager, MDUniversity of Washington
![Page 2: Treating Complications Dysphagia, Leaks, Gastric Dysfunction Following Nissen Fundoplication Brant K. Oelschlager, MD University of Washington.](https://reader035.fdocuments.in/reader035/viewer/2022062314/56649ec65503460f94bd1f4c/html5/thumbnails/2.jpg)
CENTER FOR VIDEOENDOSCOPIC SURGERY
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Postoperative Dysphagia
Improved17%
No change12%
Worse6%
Disappeared 65%
288 patients with 5 year follow-up
7 patients (2%) developed new dysphagia
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Dysphagia
Early versus
Late
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Dysphagia
Incidence Before Nissen – 43%
78% improved or resolved with Nissen New onset Dysphagia - 2% (Oelschlager BK, Am J Gastro 2007;102:1)
Causes Technical/anatomic factors Technical/anatomic factors Technical/anatomic factors Esophageal dysmotility
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Dysphagia
Avoidance Proper operative technique Control of GERD Proper work-up Pre-operative Counseling
Treatment Supportive 3-4 months Dilation if persists Look hard for anatomic problems If all fails and no anatomic problem, revise to partial
fundoplication
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Early Post-Operative Dysphagia
UGI or Endoscopy to r/o anatomic problem Patient tolerating liquids and can nourish and
hydrate In first 8-12 weeks – patience
More severe or more than 12 weeks Investigate further Consider dilation
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Causes of Dysphagia
Recurrent Hiatal Hernia
Too Tight
Incorrect Orientation
Motility
Normal Post-operative Dysphagia
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Type IA Hernia
GERD Occasionally Dysphagia
The Gastroesophageal Junction and the Wrap are Above the Diaphragm
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Recurrent Hiatal Hernia
Acute herniation (first 7-10 days) should be treated with emergent operation
Others present more insidiously and can usually be managed electively
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Causes of Recurrent Hiatal Hernia
Large Hiatal Hernia
Poor Closure
Short Esophagus
Obesity
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Biologic Mesh Reinforced Repair
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Recurrence Rate
0%
5%
10%
15%
20%
25%
Primary SIS
24%
9%*
* p = 0.04
Primary
SIS
UGI 6 Months After LPEHR
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Short Esophagus
Sandone C. Ann Surg. 2000; 232:630-40
Collis Gastroplasty
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Short Esophagus
Terry M. Am J Surg
2004; 188:195-99
WedgeGastroplasty
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Obesity & Antireflux Surgery
Normal Overweight Obese
n (%) n (%) n (%)
Recurrence 4 (5%) 7 (8%) 15 (31%)
No Recurrence 85 (95%) 80 (92%) 33 (69%)*†
* P = 0.001 vs. obese † p < 0.0001 vs. normal
Perez AR, Surg Endosc 2002;16:1380.
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Obesity & Antireflux Surgery
Morgenthal CB. Surg Endosc 2007.
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Obesity and Antireflux Surgery
Anvari M, Surg Endosc 2006,20:230
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Malpositioning
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Fundoplication Too Tight
• Technique • Dilate, but wait if
possible
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Type II Hernia
GERDDysphagiaor Both
Paraesophageal Hernia
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Type III Hernia
DysphagiaOccasionally GERD
Malformation of the wrap. The body of the stomach is used to perform the fundoplication.
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CENTER FOR VIDEOENDOSCOPIC SURGERY
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Proper Grasp for Fundoplication
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CENTER FOR VIDEOENDOSCOPIC SURGERY
(Video showing correct technique)
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Symmetrical Repair
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Non-Symmetrical Nissen
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Motility Disorders
Important to diagnose underlying primary disorders pre-op
If primary disorder found post-op treat accordingly
** (Pic of Achalasia tracing)
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Motility Disorders
Wait, Patience, Wait Dilate Revise to a Partial Fundoplication
Tracing of IEM
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Dysphagia and Normal Anatomy & Function
Wait Patience Wait Dilate Wait Revise to a Partial Fundoplication
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Management of Esophageal Leaks
Recognition Diagnosis Treatment
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Recognition
Triad of Symptom – though rarely all three present until late
Chest Pain Persistent vomiting Sub-q emphysema
Non-iatrogenic perforations picked up late because diagnosis often not considered early
Three important things to note that drive management Location Underlying cause Time from insult to intervention
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Diagnosis
CXR Can increase suspicion, but can’t rule in/out
UGI (best test) Diagnosis, severity, location
CT (being used more frequently) If can’t do UGI (Intubated, etc) Direct non-operative management
EGD (rarely) Maybe for management?
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Treatment of Post-Surgical Leaks
Small, contained leaks
Antibiotics +/- drain and wait
Leaks occurring and recognized in the first 24 - 48 hours
Consider laparoscopic reoperation, primary closure and buttress
Late occurring
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Self-Expanding Plastic Stent(SEPS)Self-Expanding Plastic Stent(SEPS)
Similar to SEMS in Concept Radial Expansile Force Less
than SEMS Causes Less Trauma than
SEMS Can be Repositioned or
Removed Indications:
Refractory benign and malignant strictures
Intrinsic or extrinsic lesions Esophageal-respiratory fistula
Polyflex®
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CENTER FOR VIDEOENDOSCOPIC SURGERY
ResultsResults
Clinical Outcome No. pts
Relief of dysphagia allowing oral feeding 27/39 (69%)
Sealing of esophageal leakage 11/15 (73%)
Stent dysfunction 6/39 (15%)
Stent migration 8/39 (20%)
Re-intervention 14/39(36%)
Stent removal b/o intolerability 5/39 (13%)
Radecke et al. Gastrointest Endosc 2005; 61:812-818
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Endoscopic TherapyEndoscopic TherapyMetallic Stents Plastic Stents
• Role still evolving•Possibly for large leak effectively drained• No control studies - don’t know denominator or how many would heal on their own
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Gastric Dysfunction
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CENTER FOR VIDEOENDOSCOPIC SURGERY
28 patients (<10%) develop new bloating
Bloating/Gastric Bloating/Gastric DysfunctionDysfunction
150
3
17 18
-12
38
88
138
188
238
288
Severity
0
1
2
3
4
5
6
7
8
9
10
150
3
17 18
-12
38
88
138
188
238
288
Severity
0
1
2
3
4
5
6
7
8
9
10
Bloating severity postop Now compared to before operation
Better(n=69)
Worse(n=78)
Same(n=41)
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Bloating
Incidence
18% before surgery 12% after surgery (Oelschlager BK, Am J Gastro 2007;102:1)
19% after (Klaus A, Am J Med 2003;114:6.)
Causes
Underlying gastroparesis
Air swallowing
Vagal nerve injury
Associated IBS (~66%) and overlapping GI diseases
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Bloating
Avoidance
Avoid Vagal trauma (Including nerve of Laterjet)
Pre-operative Counseling
Beware of associated IBS
Treatment
Recognition
Supportive
Rarely, if ever, perform surgical gastric emptying
Endoscopic pyloric dilation or Botox
Potentially convert to partial fundoplication
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CENTER FOR VIDEOENDOSCOPIC SURGERY
The Role of Pre-op Gastric Emptying Studies
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Improvement in Gastric Emptying with Fundoplication
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Effectiveness of Empyting Procedures for Gastroparesis
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CENTER FOR VIDEOENDOSCOPIC SURGERYCopyright restrictions may apply.
Watson, D. I. et al. Arch Surg 2004;139:1160-1167.
Less Bloating with Partial Fundoplication?
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CENTER FOR VIDEOENDOSCOPIC SURGERY
Strategy Post-op Gastric Dysfunction
Based on Severity Work-up
Gastric Emptying – documentation UGI – Function and fundoplication anatomy Manometry – associated motor disorders 24-hour pH - ? Reflux control
Options Emptying Procedure Partial Fundoplication Gastrectomy
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CENTER FOR VIDEOENDOSCOPIC SURGERY
“Before we consider assisted suicide, Mrs. Jones, let’s give the Prilosec a chance”