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194
J. Pandolno and D. Carlson
What Is the Current Knowledge and What Future Direction
Is Required
• Dysphagia is a common symptom after antireux procedures.
• Pre-operative assessment of symptomatic dysphagia and motility are
important in the work –up of patients referred for antireux surgery.
• The causes of dysphagia after antireux procedures are very heterogeneous and range from surgical complications related to anatomic disruption to functional dysphagia related to visceral hypersensitivity.
• Obstruction related to surgical complications should always be ruled out
with a careful endoscopy complemented by radiographic evaluation.
• New technologies, such as HRIM and FLIP may help improve detection of
abnormal EGJ opening and obstruction as a potential cause of postprocedure dysphagia.
• Using FLIP based dilation techniques could be helpful in patients with
mechanical obstruction related to a tight wrap using a staged graded
dilation.
Acknowledgements This work was supported by T32 DK101363 (JEP) and R01 DK079992
(JEP) from the Public Health service.
Disclosures: John E. Pandolno: Given Imaging/Medtronic (Consultant, Grant, Speaking),
Sandhill Scientic (Consulting, Speaking), Takeda (Speaking), Astra Zeneca (Speaking), Torax
(Speaking, Consulting), Impleo (Consultant).
Dustin A.Carlson: none.
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196
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J. Pandolno and D. Carlson
Chapter 13
Preoperative Assessment ofFailed
Fundoplication withRecurrent Hiatal Hernia
KenanUlualp, KathleenSimon, andJonC.Gould
Hiatal hernia repair and fundoplication provide excellent long-term results.
However, even with the application of the time-tested surgical principles, recurrence
rates in postoperatively-unscreened and screened patient groups may be as high as
14% and 25% respectively [1–3]. Also, recurrent hiatal hernia is recognized as the
most common cause of the failure of an antireux procedure with an incidence of
approximately 50% of all cases [4, 5]. Failed fundoplication and recurrent hiatal
hernia may be associated with a myriad of symptoms that may necessitate urgent
surgical care and present a challenging clinical problem that requires in depth
understanding of the condition.
13.1 Denition andAnatomy
Failed fundoplication is an anatomical deviation from the desired postoperative
conguration that should provide optimum result as a gastroesophageal junction
enhancement procedure. Failed fundoplication may be classied as slipped, malpo-
sitioned or loose and may or may not be together with an hiatal hernia. Similarly,
failed diaphragmatic hernia repair refers to a deviation from the targeted optimum
anatomic conguration at the time of the diaphragmatic repair that would prevent
herniation of the abdominal organs to the thoracic cavity but at the same time do not
interfere with the normal physiology. Anatomically it may be classied as a recurrence with intact hiatus, lateral defect, anterior defect, posterior defect or
K. Ulualp, M.D. • K. Simon, M.D. • J.C. Gould, M.D. (*)
Division of General Surgery, Department of Surgery, Medical College of Wisconsin,
Milwaukee, WI 53226, USA
e-mail: jgould@mcw.edu
M.A. Memon (ed.), Hiatal Hernia Surgery,
https://doi.org/10.1007/978-3-319-64003-7_13
197© Springer International Publishing AG 2018
198
K. Ulualp et al.
Table 13.1 Types of failed
fundoplication and hiatal
hernia repair
Slipped fundoplication and hiatal hernia
Slipped fundoplication
Malpositioned fundoplication
Malpositioned fundoplication and hiatal hernia
Tight fundoplication
Hiatal hernia alone
Loose fundoplication
Tight cruroplasty
anteroposterior defect, listed in increasing order of frequency [6]. Above denitions
therefore include intact fundoplications and cruroplasties that are symptomatic but
require treatment due to over-tightness (Table13.1).
13.2 Pathophysiology
Despite having been recognized over two centuries ago particularly by the work of
Bochdalek and Morgagni, pathophysiology of the hiatal hernia still remains to be
elucidated [7]. Limited data in the literature suggest; (a) unrelenting motion of the
diaphragm, (b) increased intraabdominal pressure, (c) esophageal shortening and
(d) structural changes in the diaphragm and adjacent ligaments as three main pathophysiologic mechanisms leading to hiatal hernia (Table13.2) [7–12].
Technical reasons and mesh related complications may be added to this list as
other contributing factors in the patients with previous repairs. Pathophysiologic
mechanisms leading to recurrence act by interfering with antegrade pumping of the
bolus, wound healing and principle of tension-free hernia repair.
13.3 Clinical Presentation
According to traditional understanding a recurrent hiatal hernia may or may not be
symptomatic, and asymptomatic cases are usually discovered incidentally during a
work-up for another reason. However, recent reports challenge this notion by suggesting that symptoms associated with silent hernias are much broader than previously thought and truly asymptomatic patients are rare [13–15]. Symptoms like
insidious alterations in eating habits, early satiety and postprandial dyspnea that
gradually increase over time—particularly in the elderly population—may in fact
be related with a recurrent hiatal hernia and should not be assumed to arise due to
aging [16]. Moreover, pulmonary symptoms in the patients with hiatal hernia may
also remain underappreciated likely because in elderly population symptoms such
as dyspnea is often attributed to arise from other comorbidities [17]. Therefore a
careful history taking is necessary in the patients that are assumed to be
13 Preoperative Assessment ofFailed Fundoplication withRecurrent Hiatal Hernia
Table 13.2 Pathophysiologic mechanisms and etiology of hiatal hernia
Mechanism Etiology
Increased intraabdominal pressure Obesity
Pregnancy
Straining
Chronic constipation
Weight lifting
Esophageal shortening Congenital short esophagus
Esophageal/periesophageal brosis
Chronic vagal stimuli
Tight esophageal longitudinal muscle
Structural changes in the diaphragm Reduced matrix metalloproteinases
Defective collagen formation
Structural changes in the crura Dilatation of the myobrillar spaces
Swelling of sacrotubular structures
Degeneration of myobrils
Disruption of the muscles
Decreased elastin in the ligaments In phrenoesophageal ligament
In gastrohepatic ligament
199
asymptomatic. In the more symptomatic group, complaints are mostly mechanical
symptoms due to gastroesophageal obstruction, gastroesophageal reux, strangulation and incarceration (Table13.3). While in the cases with slipped fundoplication
reux symptoms are the main components of the clinical picture, obstructive symptoms including anorexia, early satiety, dysphagia, postprandial bloating, regurgitation and weight loss become more prominent in the cases with intact fundoplication.
Incarceration and partial strangulation of displaced abdominal organs may cause
chest or abdominal pain in addition to other specic symptomology depending on
the herniated structures. Venous congestion of the mucosa due to chronic external
pressure may result in gastric ulceration (Cameron’s ulcer) and postprandial pain
[19] (Fig.13.1).
Cameron’s ulcer may cause occult bleeding and iron deciency anemia both
resolve typically after herniorraphy. Respiratory tract symptoms secondary to
chronic aspiration or intrathoracic displacement of the abdominal organs can also
be seen and may include postprandial dyspnea, chronic cough, asthma, otitis media,
sleep apnea, globus sensation, hoarseness, recurrent upper respiratory tract infections and recurrent pulmonary infections. In addition, patients may present with
urgent signs and symptoms of acute conditions such as gastric volvulus, colopleural
stula or gastropericardial stula [21–23].
Gastropericardial stula may appear as a rare complication of penetrating peptic or neoplastic ulcers of the stomach within the recurrent hiatal hernia. Diagnosis
should be suspected when a patient with an history of hiatal hernia repair present
with chest/shoulder pain, dyspnea, atrial brillation, pericardial tamponade, pyrexia
and upper gastrointestinal symptoms [23, 24]. Dyspnea and coughing with purulent
200
K. Ulualp et al.
Table 13.3 The most
common chief complaints of
the patients with recurrent
hiatal hernia [18]
Fig. 13.1 Gastric ulcers
distal to hiatal hernia at the
points of diaphragmatic
impingement on the
stomach (−Cameron’s
ulcer) [20]
Incidence (%)
Dysphagia 26
Regurgitation 24
Heartburn 18
Nausea 10
Chest pain 6
Epigastric pain 6
Dyspnea 6
Anemia 4
Nocturnal choking 2
sputum discharge accompanied by with pyrexia, and sepsis should raise suspicion
of a colopleural stula especially in the patients with history of mesh repair of an
hiatal hernia [22, 25]. Hemoptysis may add to these symptoms if the recurrence is
complicated with gastrobronchial stula [26].The classic presentation for acute
gastric volvulus is severe epigastric pain, retching without vomiting and inability to
pass a nasogastric tube (Borchardt’s triad).
Symptom assessment should be standardized by using questionnaires both for
follow-up and the quality of life measurement purposes [27–29]. However, it should
be remembered that the positive predictive value of the symptoms is limited and the
preoperative assessment should be supported by other methods [30].
In addition to symptomology, patient’s past medical history should be questioned
for the presence of chronic immunosuppression, ongoing steroid treatment, diabetes,
morbid obesity and smoking as the other factors that may adversely inuence the
wound healing and increase the probability of a re-recurrence. Obesity in particular
13 Preoperative Assessment ofFailed Fundoplication withRecurrent Hiatal Hernia
201
is a risk factor for failed antireux procedure [31]. Nicotine addiction should also be
questioned preoperatively. Tobacco usage has a well-known relation with herniations and wound healing similar to its detrimental effect on the lungs which may
appear as a systemic spillover reected in the herniation sites namely metastatic
emphysema [32].
Evaluation of the former surgery is also essential. If available, previous operative
report should be reviewed—for information about the diameter of hiatal hernia,
management of the sac, preservation of the vagus nerves, post-operative length of
the abdominal esophagus, type of the fundoplication and use of a mesh—to get an
opinion on the anatomy prior to the initial operation.
13.4 Radiologic Studies
Plain chest radiographs may reveal a mediastinal mass with or without an air-uid
level. In the latter case fundus air is absent. Although the mass is predominantly
retrocardiac and located to the left of the spine it may be large enough to even mimic
a cardiomegaly. In the absence of gas within the hernia sac plain chest radiograph
has a limited value in the differential diagnosis (Fig.13.2). However in the presence
of these ndings, particularly in elderly patients with multiple comorbidities which
may lead to diagnostic uncertainty, surgeon must maintain high index of suspicion
for the presence of recurrent hiatal hernia [21].
A barium swallow or videoesophageal study may be useful in demonstrating
the position of the hernia, location of the gastroesophageal junction, esophageal
motility and is the preferred examination for the investigation of hiatal hernia recurrence under elective conditions (Fig.13.3). Radiologic diagnosis of a sliding hiatal
hernia can be made if more than four mucosal folds are recognizable 2cm above the
diaphragm in an upper gastrointestinal barium swallow series in a prone oblique
position. Esophagus may appear tortuous and may become aperistaltic above the
hiatus suggesting supradiaphragmatically positioned esophagogastric junction.
a
Fig. 13.2 Recurrent hiatal hernia on the PA (a) and lateral plain (b) chest radiographs with airuid levels (on the left), and with bowel gas in the mediastinum (on the right)
b
202
K. Ulualp et al.
Fig. 13.3 Hiatal hernia on barium swallow
Under subacute conditions barium swallow may reveal complications like gastric
volvulus (Fig.13.4). On a dynamic study if the hernia is not reducible with the
patient in an erect position and persistent within the thorax then it is considered to
be an incarcerated diaphragmatic hernia [30].
Gastric emptying study should also be obtained in patients who had retained
barium in the stomach 2h after the end of barium swallow and on those who had
food in the stomach during gastroscopy after overnight fasting [27].
Computerized tomography (CT) is not routinely used. But it may be useful in
the elective cases without an air-uid level in direct radiographs or with a neoplasia
which requires staging and in urgent cases in which a barium swallow study is
13 Preoperative Assessment ofFailed Fundoplication withRecurrent Hiatal Hernia
Fig. 13.4 Gastic volvulus.
Note the supradiaphragmatic
position of the stomach
203
contraindicated. Presence of an hernia sac in CT examination which is greater than
2cm is radiologically accepted as a recurrent hiatal hernia (Fig.13.5). In urgent
cases, CT should be preferred to determine the size of the hernia, width of the hiatal
defect, presence of the other intra-abdominal organs in the mediastinum and to rule
out complications such as gastric volvulus or hollow organ perforation. Pneumatosis
of the gastric wall, free gas and uid outside the gastric wall within the hernia sac,
and lack of contrast enhancement of the gastric wall are the CT ndings suggestive
of a gastric necrosis [30].
13.5 Upper Gastrointestinal Endoscopy
Endoscopy should be performed in all patients for evaluation of the esophageal and
gastric mucosa for inammation, ulcers, Barrett’s esophagus, strictures and complications like mesh penetration. In addition endoscopy may play a therapeutic role in
the cases complicated with gastric volvulus. Though often it is not possible to pass
the endoscope into the duodenum the viability of the gastric mucosa can be assessed
with upper endoscopy. Insufation of the stomach can at times lead to unfolding of
the volvulus and thus be therapeutic. A well-perfused stomach decompressed with
an nasogastric tube can enable consideration of operative intervention on a