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thefundoplication.

UNDOPREVIOUSFUNDOPLICATION

■ Findingtheinferioredgesofthefundoplicationwhereitdrapesoverthe proximalstomach,especiallyontheleftsideofthegastriccardia,allowsthe edgetobetracedtowardtheanteriorfusionofa360-degreefundoplication.A similarexposureontheleftcanalsobeaccomplished,buttheleftloweredge ofthefundoplicationtendstobemorefusedalongtheneurovascularbundles ofthelessercurve.

■ Oncetheanteriorfusionofthefundoplicationisfound,itcanbeisolatedand eitherreleasedwiththeaidofelectrocauteryorseparatedbyfiringalinear cuttingstaplerbetweenthetwolimbs(FIG14).

■ Withtheanteriorportionofthefundoplicationreleased,therightlimbis dissectedawayfromthelessercurveofthestomachandrightsideofthe esophagusandreturnedtoitsnormallocationintheleftupperquadrant(FIG

15).Asthefundoplicationisdissectedawayposteriorly,theposteriorvagus

nerveshouldbesoughtandprotected.

■ Withthefundoplicationcompletelyundone,anEGDisagainperformedto assurethatthewrapiscompletelymobilizedandassessforanyperforation. Thisisdonebysubmergingtheareaofthegastroesophagealjunction(GEJ) undersalinewhileinflatingthelumenoftheesophagusandstomachwithair andlookingforanairleakexternally.

RECONSTRUCTESOPHAGEALHIATUS

■ Theesophagealhiatusisreconstructedusingpermanentsuturestoapproximate thecruraposteriorly.Pledgetscanbeusedtolimitthesawingeffectofthe sutureovertime(FIG16).

■ Ifthehiataldefectislarge,theintraabdominalpressureisdecreasedto10to12 mmHg,therebyunloadingthepressureonthediaphragmandcruralrepair.

■ Severalanteriorcruralsuturesmaybeneededifthedefectislargeandthe posterior-onlyclosureiscreatinganangleattheGEJ.

■ Thecruralreconstructionshouldresultinthecruraeffacingtheesophagus circumferentiallywithoutimpinging.

REDOFUNDOPLICATION

■ Astandardtechniqueforfundoplicationcanbeused.

9,10

Thisentailsa360degreefundoplicationifthereisadequatefundusandthepreoperative esophagealmotilityisadequate(peristalsisin70%ormoreofswallowsor esophagealbodypressureof30mmHgorgreater).A270-degree fundoplicationshouldbeusedifthesecriteriaarenotmet(Table6).

■ Fundoplicationshouldbecalibratedbycompletingthewraparounda56-to60- FrdilatorplacedacrosstheGEJ(FIG17).Itisbestifthefundusispositioned forthefundoplicationbeforethisdilatorisplaced;otherwise,thewrapcanbe verydifficulttobringaroundtheesophagusposteriorlywiththedilatorin place.

■ Twotothreepermanentsuturesthatincludetheanterioresophagusareplacedto producea2-cmlongfundoplication.

ASSESSFORPOTENTIALCOMPLICATIONS

■

OnefinalEGDisrecommendedtoassessthelocationofthewrapandlookfor anypotentialcomplications.Aretroflexviewisveryhelpfultoassurethatthe wrapisonthedistalesophagusandnottheproximalstomach(theappearance ofgastricfoldsextendingupandintothewrapsuggestsawrapthatistoo low).

CONSIDERADJUNCTS

■ Ifthehiataldissectionorundoingthewrapwasparticularlydifficult,a gastrostomytubecanbeusedtoallowgastricdecompressionandpossible gastricfeedswhilewaitingforproximalgastrointestinal(GI)functionto returnandnormalize.

PEARLSANDPITFALLS

Indicationsforsurgery anddiagnosisof failure

■Functionalreasonsforsymptomsafter

fundoplication(e.g.,misdiagnosedGERD,otherGI problems,vagalnerveinjury)cannotbecorrected withsurgery.

■Withoutevidenceofanobviousanatomicfailureor

confirmationofrecurrentGERDbypHtesting, surgeryshouldbeavoided.

Preoperativetesting ■Preoperativetestsareintendedtoassurethatcorrect

redotechniqueisperformed(e.g.,totalvs.partial fundoplication).

■Skippingtestingmaycompromiseredosuccess.

Identifyandexpose hiatalanatomy

■Injurytotheliver,lessercurveofthestomach,the

wrap,andtheesophagusismorelikelyifdissection isstartedontheright.

■Startingontheleftallowsexposureofthehiatus

beforeworkinginthemoreanatomicallycongested rightside.

Intraoperativetesting ■Liberaluseofintraoperativeendoscopytoguide

dissectionbyfrequentlyassessinganatomy

■Assessforpotentialluminalinjurypenetration.

Surgicaltechnique ■Astandardizedtechniqueadheringtokeytechnical

principleswillhelpassuresuccessfuloutcomes (Table7).

Postoperativecare ■Managingnauseatopreventretchingstartsinthe

operatingandrecoveryroomandiscriticalto minimizingtraumaearlypostoperativethatcould disrupttheredo.

■Gastricdecompressionavoidsgastricdistensionthat

coulddisruptawraporcruroplasty.

■Tubeaccesstothestomachmayallownonoperative

managementofasmallleakfoundpostoperatively.

POSTOPERATIVECARE

■ Postoperativemanagementafterreoperativeantirefluxsurgerymirrorsthecare ofanyforegutsurgerypatient.Aone-totwo-nightstayisprettytypicalifthe redoislaparoscopic,extradaysifopen.Keyaspectsofpostoperativecareare oralintakeandreturntoactivity.

■

Apreventablecauseofantirefluxsurgeryfailureisearlypostoperativeretching. Thetwomostcommonreasonsforearlypostoperativeretchingarenausea anddietaryindiscretion.

■ Patientsshouldreceivepreemptivenauseacontrolandantiemeticsandbe counseledcarefullyaboutmaintainingaliquidandsoftfooddietforatleast1 monthaftersurgery.

■ Instructingpatientstoingestonlypourableliquidsforthefirstweekafter surgeryprovidesasimpleruletofollow,andthenprovidingadetailedmenu ofacceptablesoftfoodsforanother3weekswillhelpeffectcompliancewith thepostoperativediet.

■ Toorapidadvancementtoactivitythatwillresultinincreasedintraabdominal pressurecanputsuturesandthereconstructedanatomyatrisk.Afull30days oflimitingliftingtonomorethan30lbandnovigorousexerciseduringthis timeprovidessimpleguidelinesforpatientstofollow.

■ Settingappropriateexpectationsforpatientswithregardtotheiroverall recovery,dietprogression,andresolutionofpreoperativesymptomsis important.Dysphagiamaylingerformorethan4weeksafteraredoand preparingpatientsforthislikelihoodwillallowthemtoacceptthismore readily.

■ Earlydilationmayimprovethedysphagia,butitalsoincreasestheriskof recurrentGERDandthereforeshouldbeavoidedifpossible.Wereserve dilationwithinthefirst3monthsafteranyantirefluxoperationforonlythose patientswhosedifficultyswallowingmakesithardtohandletheirownsaliva ormaintainhydration.

OUTCOMES

■ Theoutcomesofredofundoplicationcanbecomparabletoprimaryantireflux

surgery,andinpatientssufferingwithsignificantanddebilitatingsymptoms, theoperationscanreturnpatientstoanearlynormalqualityoflifewithlow morbidityandvirtuallynomortality11(Table8).

■ Thepatientrequiringmultiplereoperationsforfailedfundoplicationisaspecial situationthatdeservesspecialmention.Whenundertakingafourthredo,the failureratejumpsfromaround7%toover17%.7Wewillrarelysimply undertakearedoafterthreepriorattempts.AdividedgastroplastyandRouxen-YreconstructionforrecurrentsevereGERD,anesophagogastricmyotomy forpseudoachalasiaoresophagectomyforseverepseudoachalasiawith massivelydilatedesophagus,oranesophagojejunostomyforpooresophageal emptyingwithsevereGEJdistortionisinsteadadvised.

COMPLICATIONS

■ Complicationscanbestbeunderstood,identified,andmanagedconsideringtheir occurrence.

Intraoperative

■ Bleeding

■ Liverinjury

■ Esophagogastricperforation

■

Pneumothorax

■ Vagalnerveinjury

Postoperative

■ Pneumonia

■ Esophagealobstruction(edema)withinabilitytoswallow

■ Delayedgastricemptying

■ Atelectasisandhypoxemia

REFERENCES

1.DallemagneB,PerrettaS.TwentyyearsoflaparoscopicfundoplicationforGERD.WorldJSurg.

2011;35:1428–1435.

2.MorgenthalCB,LinE,ShaneMD,etal.WhowillfaillaparoscopicNissenfundoplication?

Preoperativepredictionoflong-termoutcomes.SurgEndosc.2007;21:1978–1984.

3.OelschlagerBK,MaKC,SoaresRV,etal.Abroadassessmentofclinicaloutcomesafter

laparoscopicantirefluxsurgery.AnnSurg.2012;256:87–94.

4.BroedersJA,RoksDJ,DraaismaWA,etal.Predictorsofobjectivelyidentifiedrecurrentreflux

afterprimaryNissenfundoplication.BrJSurg.2011;98:673–679.

5.EngströmC,CaiW,IrvineT,etal.Twentyyearsofexperiencewithlaparoscopicantireflux

surgery.BrJSurg.2012;99:1415–1421.

6.SalminenP,HurmeS,OvaskaJ.Fifteen-yearoutcomeoflaparoscopicandopenNissen

fundoplication:arandomizedclinicaltrial.AnnThoracSurg.2012;93:228–233.

7.SmithCD,McCluskyDA,RajadMA,etal.Whenfundoplicationfails:redo?AnnSurg.

2005;241:861–869;discussion869–871.

8.ParkerM,BowersSP,BrayJM,etal.Hiatalmeshisassociatedwithmajorresectionatrevisional

operation.SurgEndosc.2010;24:3095–3101.

9.DallemagneB,ArenasSanchezM,FrancartD,etal.Long-termresultsafterlaparoscopic

reoperationforfailedantirefluxprocedures.BrJSurg.2011;98:1581–1587.

10.LégnerA,TsuboiK,BathlaL,etal.Reoperativeantirefluxsurgeryfordysphagia.SurgEndosc.

2011;25:1160–1167.

11.vanBeekDB,AuyangED,SoperNJ.Acomprehensivereviewoflaparoscopicredo

fundoplication.SurgEndosc.2011;25:706–712.

Chapter7

LaparoscopicPartial Fundoplicationfor GastroesophagealReflux Disease



MarcoE.AllaixMarcoG.Patti

DEFINITION

■ Gastroesophagealrefluxdisease(GERD)isachronicconditionresultingfrom therefluxofgastriccontentsintotheesophagusandisassociatedwitha spectrumofsymptoms,withorwithouttissueinjury.

1,2

DIFFERENTIALDIAGNOSIS

■ Severalconditions,includingirritablebowelsyndrome,achalasia,gallbladder disease,coronaryarterydisease,orpsychiatricdisorderscanpresentwith heartburnasthemainsymptom.

PATIENTHISTORYANDPHYSICALFINDINGS

■ Heartburn,regurgitation,anddysphagiaareconsideredtypicalsymptomsof GERD.

■ GERDcanalsocauseatypicalsymptomssuchascough,wheezing,chestpain, hoarseness,anddentalerosions.

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