Michael Edye, MD, John Harvey, MD, Anthony Starpoli, MD, Barry Salky, MD. Mount Sinai School of Medicine
It is inevitable that a certain number of endolumenal GERD therapies will fail and some of those will come to surgical revision. As these modalities become more aggressive, the toll of unplanned effects will be greater. In this video we demonstrate typical operative findings during fundoplication following the Esophyx procedure.
The first case is a 64 year old woman who had undergone an Esophyx procedure two years prior. She had developed pleural irritation in the post-operative period. For a year she had good control of regurgitation. After developing severe discomfort with belching she noticed recurrence of her volume reflux. A barium esophagram showed post-plication changes in the esophagus consisting of contrast filled depressions in both esophagus and fundus presumably corresponding to the position of fasteners.
At laparoscopic exploration entry in to the lesser sac through the gastrohepatic omentum revealed little scarring. Fasteners were not apparent on the right side but after elevation of the esophagus from the confluence of the crural pillars, the first fastener was encountered between stomach and crus. After repairing the crura with a single figure of eight stitch a 2 cm long 360° fundoplication was constructed. We tested the tightness of the wrap using a 7 Fr Fogarty balloon that when inflated is 15 mm in diameter (45 Fr), avoiding the use of a lumenal bougie. A 4 cm gastropexy with 3-0 polypropylene completed the procedure. From experience exploring patients years after laparoscopic hiatal procedures in which gastropexy was performed, we know this to be a durable construct and believe it prevents the fundus from starting the progressive migration upward through the hiatus that defines anatomic failure.
In the second case (that we have previously reported), a 50 year old male who had undergone NDO plication and Esophyx in the past was reoperated for recurrent reflux. Again marked fixation of the esophagus and stomach with the left crus sandwiched between was found. The vagal trunk was also found transfixed by a fastener. His post-operative course was complicated by a perigastric abscess adjacent to the wrap, and very symptomatic delayed gastric emptying, that persisted more than 18 months later.
We conclude that:
1. Endoluminal therapies for GERD have evolved into meaningful surgical procedures with potential for real surgical complications.
– Blind insertion of transmural fasteners can lead to inadvertent transfixion of unrelated adjacent structures such as nerves and blood vessels.
– Incorporation of the crus with the fastener should be considered an expected result
– There is a local inflammatory, if not infective event shown by the occurrence of post-procedure pleural irritation.
2. Since fasteners communicate with the gut lumen, re-operative procedures should be considered contaminated. Avoidance of hematoma in the surgical site is of great importance and the use of perioperative prophylactic antimicrobials should be considered.
Program Number: V008