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11 Adverse Outcome andFailure Following Laparoscopic Anti-reux Surgery
Fig. 11.3 Partial posterior
fundoplication
Fig. 11.4 Partial anterior
fundoplication
173
some surgeons prefer to perform a partial fundoplication (Figs. 11.3 and 11.4),
rather than a total fundoplication [23, 24]. In fact, a partial fundoplication might be
associated with fewer functional problems—leading to persistent dysphagia postoperatively—than a total fundoplication in those patients who might have undiagnosed impaired esophageal motility [38]. However, there has been little objective
evidence to support this trend, and one might argue that the overall durability of a
partial fundoplication in the control of reux might be less reliable than that of a
total fundoplication [40–43]. Currently, there is a large agreement to perform a partial fundoplication (either posterior or anterior) in patients with impaired esophageal motility. Allaix et al. [44] suggested performing a total fundoplication as the
procedure of choice, while reserving a partial fundoplication in cases of severe
esophageal dismotility or during emergencies, when the patient presents with signs
and symptoms of incarceration or strangulation. The rationale of this approach was
that patients are frequently elderly, often they do not have preoperative esophageal
manometry, and a partial fundoplication might also be an effective form of gastropexy. Conversely, Arafat etal. [30] routinely performed manometry in all patients,
and in those with a challenging insertion, they placed the manometry catheter with
the help of an endoscope. Arafat etal. suggested performing a partial fundoplication
when manometry showed aperistalsis or severe dismotility, yet not objectively
174
C. Andol and M.P. Fisichella
dened. Auyang etal. [45] suggested performing a partial fundoplication in patients
with 90% or more failed peristaltic contractions. Cohn etal. shunned from a total
fundoplication in all patients with aperistalsis and those with severe dysphagia with
inability to pass the manometry catheter. DeMeester and other authors reported that
a fundoplication should always be added to all HH repairs and the type of fundoplication should be selected on the basis of the patient’s esophageal motility [32–34].
In the studies by Ponsky and Stiven, of 142 patients undergoing HH repair with
a partial fundoplication–141 partial posterior (270Toupet) and 1 partial anterior
(180Dor, due to the anatomical difculties in performing a posterior wrap)—at a
mean follow-up of 17months, no patient reported reux symptoms, while 4 (3%)
patients (1in the Ponsky and 3in the Stiven study) presented with postoperative
dysphagia requiring endoscopic dilation [23, 24]. In two studies, by Mittal etal.
[10] and Van Der Westhuizen etal. [10, 11] no fundoplication was performed in
patients with impaired esophageal peristalsis, and in patients with normal motility,
the type of fundoplication was chosen according to gastric anatomy and fundus
compliance. Overall, on a combined number of 225 patients, 150 (66.5%) underwent total fundoplication, 18 (8%) partial posterior fundoplication, 1 (0.5%) par-
2
tial anteriorfundoplication, 4 (2%) a gastric bypass for obesity (BMI[ 40kg/m
),
and 52 (23%) had no fundoplication. Postoperatively, at a mean follow-up of
29months, 18 patients (12%) who underwent a total fundoplication presented with
dysphagia, with 10 requiring endoscopic dilation. Eleven patients presented postoperatively with symptoms of reux, seven after a total fundoplication (4.6%), and
four after PEH repair alone (7.7%), yet no postoperative pH monitoring was performed [10, 11]. Interestingly, Dallemagne etal. and Leeder etal. routinely performed a preoperative manometry and stated that they considered a total
fundoplication as the procedure choice in all patients, while they reserved a partial
fundoplication only to those with little compliance of the gastric fundus [12, 26].
Overall, on a combined number of 118 patients (96 total fundoplication, 11 partial
anterior, and 11 partial posterior), among patients with total fundoplication, three
had postoperative dysphagia (3%); two required a conversion to a Toupet fundoplication and 1 improved after endoscopic dilation. Among these 118 patients, 21
(18%) had postoperative reux symptoms. Gouvas et al. [21] divided the 16
patients with abnormal esophageal motility in two subgroups: one group of nine
patients who received a total fundoplication, and another group of seven patients
who received a partial posterior fundoplication. At 12months of follow-up, they
showed that four patients (44%) after a total fundoplication and two patients (29%)
after a partial fundoplication presented with postoperative dysphagia. Conversely,
four patients (57%) presented with reux symptoms after a partial fundoplication,
while one patient (11%) presented with GER symptoms after a total fundoplication. In addition, all 16 patients underwent postoperative esophageal pH monitoring and all of those with a partial fundoplication had an abnormal amount of reux
(mean DeMeester score of 33), while 4 out of 9 patients (44%) after a total fundoplication had an abnormal amount of reux (mean DeMeester score of 39).
11 Adverse Outcome andFailure Following Laparoscopic Anti-reux Surgery
175
11.3 Conclusions
These data have shown that in the majority of surgeons prefer to add a fundoplication to all HH repairs, preferably a total fundoplication in patients with normal
esophageal motility. Despite this widespread tailored approach, as of today there is
no evidence in literature that a fundoplication is better than another in preventing
reux and avoiding dysphagia in patients undergoing hiatal hernia repair, and the
small prospective/retrospective and non-comparative studies in the literature do not
help in drawing denitive conclusions. Based on our experience, we strongly suggest performing esophageal testing, when possible, and adopt a tailored approach
performing a total fundoplication only in patients with effective esophageal
motility.
What Is the Current Knowledge and What Future Direction
Is Required
• Most of the authors agree that a fundoplication should be added to a hiatal
hernia repair.
• When possible, a complete workup including pH monitoring and highresolution manometry should be performed before planning an operation.
• The majority of surgeons embrace a tailored approach when choosing the
antireux procedure, performing a total fundoplication only in patients
with effective esophageal peristalsis.
• A partial anterior or posterior fundoplication should be considered for
patients with esophageal motility disorders.
• Further study is required to validate this tailored approach.
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Endosc Percutan Tech. 2013;23(5):449–52.
25. Alicuben ET, Worrell SG, DeMeester SR.Impact of crural relaxing incisions, collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia
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26. Dallemagne B, Kohnen L, Perretta S, Weerts J, Markiewicz S, Jehaes C.Laparoscopic repair
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C. Andol and M.P. Fisichella
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Endosc. 2001;15(7):691–9.
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L.Partial fundoplication for gastroesophageal reux. Surg Endosc. 1997;11(5):445–8.
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177
Chapter 12
Post-operative HRIM andFLIP forDysphagia
Following Antireux Procedures
JohnPandolno andDustinCarlson
12.1 Introduction
Post-operative dysphagia after an antireux procedure is a common problem that
requires a thorough evaluation of anatomy and physiology to determine whether the
complaint is due to obstruction at the esophagogastric junction or a defect in peristalsis that was either missed or underestimated during the pre-operative assessment. Many tools are helpful in this assessment and the rst step is to assess the
anatomy of the EGJ as antireux procedures focus primarily on attempting to augment the barrier function of this anatomic zone. This can be accomplished with a
careful endoscopy or a barium esophagram to determine whether the antireux procedure is intact or potentially disrupted with or without herniation. Additionally,
these tools are also important in ruling out strictures and other mechanical problems
related to the various endoscopic and surgical approaches.
High-resolution impedance-manometry (HRIM) and Functional lumen imaging
probe (FLIP) evaluation should be performed when there is no overt cause of postoperative dysphagia found on endoscopy and barium esophagram. High-resolution
impedance manometry can assess the ability of the lower esophageal sphincter
(LES) to relax and can also provide surrogate information regarding obstruction via
an assessment of intrabolus pressure. Additionally, peristaltic function and bolus
clearance can also be assessed during HRIM to determine whether there are severe
abnormalities in motor function that will lead to severe bolus retention once the
antireux barrier is improved. The FLIP procedure is a complementary approach
that can be used endoscopically to assess the opening dynamics of the EGJ.Although
the FLIP has been primarily utilized in the evaluation of achalasia, this approach
J. Pandolno (*) • D. Carlson
Division of Gastroenterology and Hepatology, Department of Medicine,
Feinberg School of Medicine, Northwestern University,
676 St Clair St, Suite 1400, Chicago, IL 60611-2951, USA
e-mail: j-pandolno@northwestern.edu
M.A. Memon (ed.), Hiatal Hernia Surgery,
https://doi.org/10.1007/978-3-319-64003-7_12
179© Springer International Publishing AG 2018
180
can be applied to the evaluation of post-fundoplication dysphagia as the primary
focus is documenting normal EGJ opening.
The current chapter will focus on the work-up of post-operative dysphagia after
antireux procedures with the assumption that there are no overt abnormalities in
anatomy noted on endoscopy or barium esophagram. Additionally, the approach to
these patients will be generalized across both the endoscopic and surgical approaches
as the primary goal of HRIM and FLIP are to rule out a major motor disorder and
obstruction at the EGJ.
J. Pandolno and D. Carlson
12.2 Algorithm: Evaluation ofDysphagia After
anAntireux Procedure
It is not uncommon for a patient to note some degree of dysphagia after an antireux
procedure and the difcult part of the early evaluation is determining whether the
complaint is transient or will persist. A feeling of food hanging up or that there is a
foreign body sensation is expected during the early post-procedure period (rst
30days) because the anatomy has been altered to prevent reux and thus, inherently
this area will be more obstructive to passage of liquid and food. As long as patients
are maintaining their weight, not requiring narcotics for pain or regurgitating (especially at night), I will monitor the patient closely during this early post-procedure
time-frame. After 30days, if the patient continues to have symptoms or the symptoms are progressive or associated with weight loss and nocturnal regurgitation,
evaluation with endoscopy and/or barium esophagram should be performed to
assess the anatomy (Fig.12.1). If there is no overt herniation or disruption, or there
is a suggestion that an obstruction is occurring due to these abnormalities, the next
step should focus on assessing EGJ opening. This can be accomplished by performing an EndoFLIP™ evaluation during the endoscopic evaluation. Alternatively, this
can be accomplished with a barium esophagram using a 12.5mm barium tablet if
FLIP is not available. If there is an obstruction noted and the anatomy is conducive
to dilation [no frank herniation or disruption], I will typically perform a throughthe- scope (TTS) balloon dilation to 20mmHg with the caveat that this will likely
need to be repeated and escalated if no change in symptoms occur to a higher diameter using either the EsoFLIP dilator balloon or the standard pneumatic balloon
dilators from 30 to 35mm. Patients without evidence of obstruction should undergo
HRIM evaluation and in most instances I will typically place this during endoscopy
to expedite the work-up and improve patient adherence. The typical swallow protocol will be used to determine whether peristaltic function has changed and whether
an underlying primary motor disorder was undiagnosed before the operation. It is
important to realize that the operation can alter motor function and pseudoachalasia
may be difcult to discern from primary achalasia that was missed. The preoperative manometry is usually very helpful as it is unlikely that achalasia has
Approach to patient with dysphagia after an antrireflux procedure
12 Post-operative HRIM andFLIP forDysphagia Following Antireux Procedures
[Surgical/Endoscopic]:
-symptoms may be dysphagia, regurgitation or food impaction
Symptoms associated with weight-loss, severe
regurgitation and/or continued requirement of narcotics
181
Before 30 days post-procedure
no
EGD
Hiatus hernia or disruption with or
without obstruction
no
Esophagitis/ Stricture
no
FLIP
Evidence of obstruction
no
HRIM
Major Motor Disorder/EGJOO
no
Functional Dysphagia
Treat with supportive care, diet
therapy and behavioural
intervention
no
yes
Considered failure and consider surgical options to correct
yes
yes
yes
pseudoachalasia related to the operation or narcotic use
Fig. 12.1 Management algorithm for patients presenting with dysphagia after an antireux procedure. Patients presenting with symptoms that are severe requiring pain medication and/or associated with regurgitation and weight loss require some evaluation to primarily rule out an anatomic
or mechanical problem related to herniation or disruption. A step-wise approach is used that ultimately will lead to a diagnosis consistent with functional dysphagia if both FLIP analysis and
HRIM are negative
yes
defect and treat reflux. Would place back on PPI.
Medical management with PPI and dilation therapy if
stricture is noted. Consider procedure a failure.
Dilation with a TTS balloon and gauge response.
If no response-may escalate dilation therapy with
Treat accordingly with the caveat that this could be
UGI Contrast
Disrupted or Frank
herniation
yes
pneumatic balloon [EsoFLIP].
UGI with a barium tablet may be helpful.
if ongoing.
evolved over a short time period and occasionally, interventions with amyl nitrite
can be helpful to differentiate a mechanical obstruction (no relaxation to amyl
nitrite) from achalasia (relaxation in response to amyl nitrite). Additionally, narcotics can be associated with a type III achalasia pattern or an EGJOO and repeat
manometry off these medications should be attempted if possible. Patients without
evidence of obstruction or a major motor disorder will typically be treated as if they
meet criteria for functional dysphagia and will be referred for cognitive behavioral
therapy, hypnosis and dietary consultation.
182
J. Pandolno and D. Carlson
12.3 High-Resolution Impedance Manometry (HRIM)
Esophageal manometry is recommended for the evaluation of non-obstructive dysphagia and prior to anti-reux surgery [1]. Although not a primary indication,
manometry has been used to assess persistent dysphagia in post-fundoplication
patients and extrapolating from protocols for dysphagia appears to be reasonable.
High-resolution manometry (HRM) utilizes catheters with pressure sensors spaced
1–2cm apart that are positioned spanning from the hypopharynx to the stomach to
simultaneously measure pressures generated along the entire length of the esophagus. Sophisticated software processes the HRM pressure output to generate esophageal pressure topography (EPT) plots that represent esophageal motility and
sphincter function on color-coded, pressure-space-time plots [2]. Analysis of EPT
plots is facilitated by objective metrics of esophageal function that can be applied to
classify individual swallows and generate esophageal motility diagnosis according
to a consensus-generated scheme: the Chicago Classication [3, 4]. Once again, the
Chicago Classication was not meant to assess post-fundoplication dysphagia,
however, it is reasonable to utilize the current metrics given the fact that asymptomatic post-fundoplication patients appear to have similar normal values when compared to controls [5, 6].
Over the last 5years, there has been an increased interest in combining HRM
technology with impedance and to leverage the information on bolus transit from
impedance with the improved accuracy and detail of HRM. Basically, this approach
gives you the “best of both worlds” and allows for more sophisticated analysis of
esophageal function. Impedance electrodes are usually spaced at 2cm intervals to
straddle pressure sensors and provide an assessment of bolus transit/retention and a
more robust assessment of IBP.
12.3.1 HRIM Study Protocol
After catheter calibration and application of topical anesthetic to the patient’s nare
and/or throat, the HRM catheter is placed transnasally and positioned with the pressure sensors spanning form the hypopharynx, through the esophagus, and 3–5cm
into the stomach. After a brief period for patient acclimation, a baseline of resting
pressures can be obtained over approximately 30s of easy breathing and without
swallows. Conrmation of correct placement of the catheter traversing the esophagogastric junction (EGJ) can be conrmed during this period by recognition of the
presence of the pressure inversion point (PIP), i.e., the point at which the inspirationassociated negative intrathoracic pressure inverts to the positive intra-abdominal
pressure. Having the patient take deep breaths facilitates identication of the PIP by
augmenting the EGJ pressure and exaggerating the intra-thoracic and intra- abdominal
pressures. This can be helpful in patients after hernia repair to determine whether
there is recurrence, however, this should usually be noted during endoscopy.
12 Post-operative HRIM andFLIP forDysphagia Following Antireux Procedures
183
The Chicago classication is based on the analysis of ten supine, liquid (5-mL
water) swallows and is validated for use in the non-surgical patient. Since one of the
primary objectives in assessing patients after antireux procedures focuses on dening subtle obstruction, additional components can be added to the manometric protocol to supplement clinical interpretation. Inclusion of upright swallows can be
useful to help distinguish if abnormal pressure signals, particularly at the EGJ, are
related to anatomic abnormalities, such as vascular artifact or hiatal hernia [7].
Incorporating swallows of different bolus textures (thick liquids or solid) or a test
meal may also be benecial to uncover symptoms and/or abnormal ndings of
esophageal function [8]. Multiple, rapid swallows (generally 5 swallows of 2-mL
water spaced 2–3s) can also be included to elucidate defects in deglutitive inhibition (if esophageal contractions occur during the course of the multiple swallows)
and to assess for peristaltic reserve [9, 10]. Peristaltic reserve can be identied by
augmentation of the esophageal contractile vigor following the multiple swallows
and may help predict risk of developing post-fundoplication dysphagia or detect an
etiology for symptoms in an otherwise normal manometry study [9, 10].
Our institutions standard protocol includes (1) Ten supine, liquid swallows, (2)
ve upright liquid (5-mL water) swallows, (3) one multiple, rapid swallows (ve
swallows of 2-mL water spaced 2–3s), and (4) provocative swallows with a thick
liquid (applesauce) and solid (crackers) food bolus based on suspicion for obstruction and a nal 200 mL mixed saline swallow to mimic a timed barium
esophagram.
12.3.2 HRIM Interpretation
Interpretation of EPT studies in the patient presenting with dysphagia after an antireux procedure can be performed in a stepwise, hierarchical fashion directed by
the Chicago Classication (Figs.12.2 and 12.3) [4]. There are, however, several
caveats to note when applying the Chicago Classication to EPT analysis for
patients who have undergone an antireux procedure. First, the absolute values
reported in the Chicago Classication (and in the remainder of this review) are
based on normative values generated from supine swallows of 5-mL water using the
Sierra HRM assembly (Medtronic Inc., Shoreview, MN). Thus, interpretation using
different catheter assemblies, patient positions, and/or boluses, needs to account for
expected differences in normative values of EPT metrics, which are summarized in
a review by Herregods and colleagues [11]. Additionally, there are studies that have
presented data on HRM metric values in patients who are asymptomatic after fundoplication. These values are very similar to what is seen in the published normative
ranges for non-surgical controls, however, small elevations in IRP are probably
within what would be expected and a careful assessment of bolus transit may help
determine whether a slightly elevated IRP is contributing to the current symptoms.
More recently, a new analysis paradigm has been introduced that combines the
analysis of HRM and impedance. Automated impedance manometry (AIM) utilizes