Complications - Nissen fundoplication

Injury to left hepatic lobe with hemorrhage

• Manage by electrosurgery, argon beamer, application of hemostyptics, sutures, possibly convert to open procedure

Splenic injury with hemorrhage

• Manage as in liver injury, possibly splenectomy or conversion to open procedure required

Injuries to the esophagus and gastric wall

• Suspected:
• > Dye injection through gastric tube
• > Allows confirmation of very small mural lesions with luminal opening
• > Depending on the size of the defect laparoscopic suture or conversion to laparotomy with open management

Intraoperative pneumothorax

• Origin: Pleural injury during mediastinal mobilization of the lower esophagus, thereby allowing CO₂ to escape into the pleural cavity.
• Only important in cardiopulmonary problems

Stable patient:

• Continue procedure without chest tube
• After evacuation of the pneumoperitoneum rapid resolution of the pneumothorax can be expected

Unstable patient (=increasing ventilation pressure, poor oxygenation)

• Reduce pressure in peritoneal cavity, possibly having to release the CO₂ completely
• In persistently poor oxygenation: Insert chest tube and continue with procedure
• Conversion to open procedure rarely necessary

Persistent dysphagia

Early temporary dysphagia must be differentiated from swelling in the wake of the procedure, which resolves spontaneously after a few weeks, and from persistent dysphagia.

Origins:

• Incorrect wrap position
• Wrap too tight or too long
• Propulsive esophageal disorder and dysregulation of the peristaltic wave in swallowing

Treatment:

• Bougienage (4 weeks after surgery the earliest)
• In confirmed stenosis with unsuccessful bougienage: Revision surgery
• After partial wrapping the rate of dysphagia is lower. 360° wraps should be avoided in propulsive esophageal disorders and dysregulation of the peristaltic wave in swallowing.

Denervation syndrome

Origin:

• Lesion of vagal innervation

Outcome:

• Delayed gastric emptying
• Bloating
• Diarrhea

Treatment:

• Medication (e.g. prokinetics)
• In some case pyloroplasty

Insufficient or ruptured wrap

Origins:

• Wrap too floppy or complete failure (e.g., fundus wrap fixated with absorbable sutures)

Outcome:

• Persistent postoperative reflux

Treatment:

• Revision surgery/de novo wrapping; if initial procedure was minimally invasive revision may also be performed laparoscopically

Telescope phenomenon

Origin:

• Insufficient fixation of fundus to stomach and esophagus results in wrap flipping and superior migration of the cardia, where the wrap now encircles the body of the stomach.

Outcome:

• Reflux from the newly formed fundus pouch combined with dysphagia due to fundus constriction by the wrap.

Treatment:

• Revision surgery/de novo wrapping; also possible laparoscopically

Gas-bloat syndrome

In the literature the term “gas bloating” describes a number of symptoms following fundoplication which supposedly arise from the gas induced distension of the stomach accompanied by inability to eructate. This includes:

• Epigastric complaints
• Bloating
• Pain in the back, chest and shoulders
• Inability to eructate
• Tympanitis

Often GERD patients already complain of gas-bloat syndrome before surgery, which is caused by frequent swallowing of saliva because patients are attempting to lessen their acid induced GERD complaints. Since 10 mL - 20 mL are swallowed each time when swallowing, to a certain extent the patients necessarily indulge in aerophagia which they often maintain after surgery.

Avoiding heavy meals and carbonated beverages is helpful, and bougienage may be an option. Revision surgery for gas-bloat syndrome should only be considered when suffering is truly severe.

It appears that gas-bloat syndrome is less likely in partial fundoplications.