Creation of a Partial Fundoplication

There are several types of partial fundoplications. The most commonly performed is the Toupet fundoplication . In this operation, the gastric and esophageal dissections, as well as the repair of the crura, are the same as for a 360° fundoplication. The fundoplication must be created with the fundus, and not the body, of the stomach.

The key difference between Toupet and Nissen fundoplication is that the stomach is positioned 180° to 270° in a Toupet fundoplication compared with 360° in a Nissen fundoplication around the posterior aspect of the esophagus. On both sides of the esophagus, the most cephalad sutures of the fundoplication incorporate the fundus and crus. The remaining sutures anchor the fundus to the esophagus.

If an anterior Dor fundoplication is to be performed, there is no need to disrupt the posterior attachments of the esophagus. We recreate the angle of His by approximating the medial fundus to the left crus and the esophagus on the left. Next the fundus is folded over the anterior aspect of the esophagus and anchored first to the right crus and then the esophagus.

Upon completion of the fundoplication, our standard practice is to perform an esophagogastroduodenoscopy (EGD) to evaluate the fundoplication. We ensure that the esophagus is straight, and the lower esophageal sphincter opens easily with insufflation. A retroflexion view is useful to evaluate the adequacy of the wrap and rule out presence of any redundant stomach above the wrap.

Postoperative Management

With the exception of patients with comorbid medical conditions requiring cardiac or pulmonary monitoring, postoperatively most patients are admitted to a general surgical floor for overnight observation. They are given a clear-liquid diet the evening of surgery, along with pain and nausea medications as needed. They are ambulated in the hallways with nursing assistance. The following morning, postoperative day 1, they are advanced to a full-liquid diet. Discharge requirements include tolerance of a diet to maintain hydration and nutrition, adequate pain control on oral analgesics, and ability to void without a Foley catheter. After discharge from the hospital, patients can gradually introduce soft, easy-to-swallow, and moist foods into their diet, avoiding difficult to swallow foods like bread, raw vegetables, and dry meats until their 2-week follow-up visit. We additionally advise all medications larger than a baby aspirin be in liquid form, crushed or opened during this time, and routinely have patients take simethicone with all meals to avoid troublesome gas bloat in the early postoperative period. Antacid therapy is held at discharge. Patients should expect to resume a diet without limitations in about 4 to 6 weeks .

Side Effects and Perioperative Complications

Laparoscopic antireflux surgery is a safe operation when performed by experienced surgeons. Thirty-day mortality rates are less than 1% [8]. Complication rates vary according to surgeon, technique, and extent of patient follow-up. Since 1993, using the National Inpatient Database, the rate of complications following surgery has fluctuated between 4.7% and 8.3% [9–11]. These complications are typically minor and not specific to antireflux procedures; these include urinary retention, wound infection, venous thrombosis, and ileus. Complications specific to antireflux surgery include capno-/pneumothorax, gastric/esophageal injury, splenic/liver injury, and bleeding. Additionally, antireflux surgery can result in postoperative side effects, including bloating and dysphagia.

Side Effects

It is not uncommon for patients to have mild, temporary dysphagia during the first 2 to 4 weeks postoperatively, thought to be a result of postoperative edema of the wrap and the closure of the esophageal hiatus. In the vast majority of these patients, the dysphagia resolves spontaneously. A second, but less common, cause of dysphagia is a hematoma of the esophageal/gastric wall that develops as a result of the sutures used to create the fundoplication . Although this may create more severe dysphagia initially, patients are generally able to tolerate secretions and liquids; typically, dysphagia resolves over a few days. In either of these scenarios, surgeons should ensure that patients can maintain their nutrition and hydration on a liquid or soft diet, and additional interventions are rarely needed.

In the event of severe dysphagia and inability to tolerate liquids, a UGI should be obtained to ensure that no anatomic abnormality exists, such as an early hiatal hernia or obstruction at the esophagogastric junction. Assuming there is no early recurrent hiatal hernia or true obstruction and patients can tolerate liquids, an expectant management should be followed for 3 months. If patients cannot maintain hydration, or dysphagia persists beyond 3 months, another UGI should be obtained to ensure that there is no anatomic abnormality that could explain the dysphagia. If the UGI demonstrates an appropriately positioned fundoplication below the diaphragm, an EGD with dilation of the GEJ may provide relief.

Aerophagia – the normal swallowing of air – is the main factor leading to gastric distention, and the physiologic mechanism for venting this air is belching, occurring via vagal-mediated transient LES relaxation. Following antireflux surgery, patients have decreased belching due to fewer transient LES relaxations [12] and therefore can experience troublesome abdominal bloating. In a study on the impact of gas-related symptoms on the outcomes of both Nissen and Toupet fundoplications, Kessing and colleagues [13] found that preoperative belching and air swallowing were not predictive of postoperative gas-related symptoms, including bloating. They concluded gas-related symptoms to be caused by gastrointestinal hypersensitivity to gaseous distention. In this study, all patients experienced postoperative normalization of esophageal acid exposure. However, despite reflux resolution, patients who developed postoperative gas symptoms were less satisfied when compared with patients who did not experience these symptoms. We have found dietary and behavioral interventions such as the routine use of simethicone and avoiding chewing gum, straws, and carbonated beverages, particularly in the first few weeks after surgery, to be helpful.

During the early postoperative period, patients who report persistent nausea or demonstrate inadequate intake of a liquid diet should undergo an abdominal radiograph. If significant gastric distention is identified, a nasogastric tube can safely be placed to decompress the stomach for 24 hours. Few patients require further intervention for gastric bloating.

Perioperative Complications

Although capnothorax is one of the more common intraoperative complications, it is reported to occur in only approximately 2% of patients [14]. While postoperative chest radiographs are not routinely obtained, pleural violation should be identified intraoperatively, and the anesthesia team should be informed. The pleural violation results in intrathoracic infusion of carbon dioxide, which is absorbed rapidly. Because no underlying lung injury exists, the lung will re-expand without problems. When violation of the pleura is identified intraoperatively, the pleural should be reapproximated with a suture or endoloop if technically feasible, and a postoperative radiograph should be obtained. If a pneumothorax is identified on this radiograph, patients may be maintained on oxygen therapy to facilitate resolution. Unless patients experience shortness of breath or the need for persistent oxygen therapy to maintain oxygen saturation, no further radiographs are obtained.

Gastric and esophageal injuries rates in the literature are approximately 1% in patients undergoing minimally invasive antireflux surgeries [15–17]. These injuries tend to result from unnecessarily rough manipulation of these organs or during the passage of a bougie into the stomach: for these reasons we do not routinely use a bougie. Not surprisingly, injuries are more likely to occur in re-operative cases and should be rare during initial operations. If identified at the time of operation, repair of these injuries can be performed with suture or stapled wedge resection, as appropriate, without sequelae. When the injury is not identified intraoperatively, patients commonly require a return to the operating room to repair the viscus, unless the leak is small and contained.

The incidence of splenic injury resulting in bleeding is about 2.3% in population-based studies, and major liver injury is rarely reported [17]. Although splenic bleeding is relatively uncommon and when it does occur, usually it is easily controlled with pressure and topical hemostatic agents, in rare cases, it can require splenectomy. Splenic parenchymal injury most commonly occurs during mobilization of the fundus and greater curvature of the stomach. This is one of the reasons we prefer to begin with the left crus approach, dividing the phreno-gastric ligament and the short gastric vessels early in the operation. Care must be taken during mobilization of the fundus to avoid excessive traction on the spleno-gastric ligament. Partial splenic infarction is another type of injury that can occur. This typically occurs during transection of the short gastric vessels and inadvertent coagulation of superior pole branch of the main splenic artery [18]. Partial splenic infarction rarely causes any symptoms, and it is generally well tolerated. Finally, lacerations and subcapsular hematomas of the left lateral section of the liver can be avoided by carefully retracting it out of the operative field using a fixed retractor .

Conclusions

Despite numerous randomized clinical trials and meta-analyses, there still remains controversy as to which fundoplication provides the most durable control of reflux and the best side-effect profile. A likely reason for this is that these studies vary in terms of patient characteristics, selection, and operative technique. The only consistent finding in these studies is that anterior fundoplications provide less durable control of GERD than posterior partial and total fundoplications. In our practice, we routinely use preoperative manometry to evaluate for esophageal dysmotility, and if present, we proceed with a Toupet fundoplication. In the presence of normal motility, we perform a Nissen fundoplication. An anterior (Dor) fundoplication is mostly used as an adjunct to a Heller myotomy. We follow all of our patients for the first 12 months and perform upper GI studies at their follow-up to better understand their individual outcomes. We also use postoperative symptom score questionnaires to help us better characterize our patients’ outcomes.