You need to log in to watch this media!

Click here to log in.

Complication of fundoplication: esophageal stenosis at the hiatal orifice

Authors

Abstract

The video demonstrates the laparoscopic surgical management of an unusual case of postoperative dysphagia following a Nissen's fundoplication for reflux disease.

Classification

complex cases

Keywords

complication, GERD, fundoplication, esophageal stenosis, hiatal orifice

Media type

Duration

09'40''

Publication

2008-07

Popular

Favorites

Audio

Subtitles

E-publication

WeBSurg.com, Jul 2008;8(07).
URL: http://www.websurg.com/doi-vd01en2385.htm

Complication of fundoplication: esophageal stenosis at the hiatal orifice

1. Case presentation 00'15''

This video reports the case of dysphagia in a patient having had a previous laparoscopic fundoplication for a well-documented GERD. This patient had a first operation, which was uneventful. The postoperative X-rays were normal. We can see in this video that the high pressure zone opens quite well. The postoperative clinical outcome was normal as well. This patient had a normal dysphagia during 4 weeks after the operation but he came back in December, so 3 months after the operation with a recurrent dysphagia and a barium swallow was performed. On this picture, we can see that there is a quite large and long zone of stenosis at the lower part of the esophagus and when we look at the position of the diaphragm, we can see that the stenosis is above the diaphragm so we can imagine 2 hypotheses to explain that. The first one is the herniation of the fundoplication through the hiatal repair and the 2nd cause is the stenosis at the level of the diaphragm.

2. Case commencement 01'25''

So the patient did not respond to endoscopic dilation and we decide to redo this patient.

3. Initial dissection and adhesiolysis 01'35''

When entering the peritoneal cavity, we can see that there are no adhesions within the general cavity but on the contrary, when we are approaching the hiatus, we can find very strong adhesions in a quite intense fibrotic response even if we are 3 months after the 1st procedure. So we start with this progressive dissection of these strong adhesions here on the left liver lobe. We can see that tissues are very inflammatory with very easy bleeding from the different dissection planes. So the goal is to find the anatomy that we left at the 1st operation. So here we can see that we are dividing the adhesions above the pars flaccida of the lesser omentum. We know that in the 1st operation we kept the hepatic branches of the vagus trunk, so it’s a good landmark to find again the right dissection plane but as you can see, the adhesions are very inflammatory and a good trick in this condition is to use surgical gauze to clear the area and sometimes you have to use a suction device in the left hand to have a very clear field at all the different steps. Because we have to work on the hiatus, we decide to take down these hepatic branches of the vagus trunk that were kept safe at the 1st operation, but we need a very clear view on the diaphragm and the exit of the esophagus from the diaphragm. And again, we were astonished to find this very inflammatory process, strong adhesions around the esophagus and all the surface of the diaphragm so we knew that the stenosis was above the diaphragm or at the level of the diaphragm so we decide to approach the esophagus in this area very carefully because we know that in these conditions and this inflammatory process, the tissues are very fragile. So it has to be a very clear and very precise dissection, plane after the older plane, being sure that we are not injuring the esophagus.

4. Examination of hiatus and in-situ wrap 04'15''

5. Take-down of prior crural repair 04'58''

Here we can see these very strong tissues. We can find some residual sutures after the 1st operation. So we’re trying to find a more normal dissection plane, one that we found during the 1st operation and as soon as we find this plane, we can find a normal part, a normal segment of the lower esophagus and so by using repeatedly the esophageal bougie, we try to identify the cause of obstruction and here we can see that by opening this crural repair, the bougie now can be passed down through the hiatus and through the fundoplication. What we decide at this stage is not to dismantle the fundoplication, which is not the cause of the obstruction but to work a little bit more on the diaphragm and trying to enlarge the diaphragmatic repair in order to free the esophagus. As soon as we find that the bougie is passing down this repair very easily, we can stop the operation. So we’re opening on the side but we’re also opening on the anterior aspect of the diaphragmatic hiatus and again by passing down the bougie, we could feel that bougie was going very easily into the stomach.

6. Resolution of obstruction 06'43''

This is a very rare cause of dysphagia but we don’t know exactly the mechanism that leads to this very strong inflammatory response, scarring tissues and of course the risk is that of recurrence so usually we’re following very closely this patient and we can see on the postoperative X-ray that now the high pressure zone is in the right position; there’s no stenosis above the diaphragm any more,

7. Postoperative outcome on follow-up examination 07'17''

and 3 months after this redo operation, this patient is still doing very well. He had of course postoperative dysphagia but now he’s coming back to a normal diet.

Username
Password
	Remember me (needs cookies)