Laparoscopic partial fundoplication after lung transplant in a patient with severe esophageal motility disorders (scleroderma)

Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease before and after lung transplantation. In addition to problems with the lower esophageal sphincter, systemic diseases such as scleroderma and cystic fibrosis can diminish esophageal and gastric motility. After thoracic transplantation, esophageal and gastric motility often are negatively affected by damage to the vagus nerve and certain medications. Remodeling of the thoracic cavity also may alter the mechanics of esophageal muscle contraction. After transplantation, fundoplication may improve pulmonary function and prevent complications such as bronchiolitis obliterans syndrome. This is the case of a 57-year old patient with scleroderma 8 months after lung transplantation for idiopathic pulmonary fibrosis (IPF). The patient presented with typical GERD symptoms, not responsive to a high dose of PPI. The trocar placement is the same as for a standard Nissen fundoplication. The video shows each surgical step carefully and demonstrates how to correctly perform esophageal and mediastinal dissection in case of a previous lung surgery.

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Laparoscopic   partial   fundoplication   after   lung   transplant   in   a   patient   with   severe   esophageal   motility   disorders   (scleroderma)

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease before and after lung transplantation. In addition to problems with the lower esophageal sphincter, systemic diseases such as scleroderma and cystic fibrosis can diminish esophageal and gastric motility. After thoracic transplantation, esophageal and gastric motility often are negatively affected by damage to the vagus nerve and certain medications. Remodeling of the thoracic cavity also may alter the mechanics of esophageal muscle contraction. After transplantation, fundoplication may improve pulmonary function and prevent complications such as bronchiolitis obliterans syndrome.
This is the case of a 57-year old patient with scleroderma 8 months after lung transplantation for idiopathic pulmonary fibrosis (IPF). The patient presented with typical GERD symptoms, not responsive to a high dose of PPI. The trocar placement is the same as for a standard Nissen fundoplication. The video shows each surgical step carefully and demonstrates how to correctly perform esophageal and mediastinal dissection in case of a previous lung surgery.
Classification
complex cases
Keywords
Laparoscopic partial fundoplication, lung transplant, severe esophageal motility disorders, scleroderma, idiopathic pulmonary fibrosis, IPF
Media type
Duration
05'50''
Publication
2009-03
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E-publication
WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2552.htm

Laparoscopic   partial   fundoplication   after   lung   transplant   in   a   patient   with   severe   esophageal   motility   disorders   (scleroderma)

5. Mediastinal dissection 02'14''
Now to the mediastinal dissection. The aim of the subsequent dissection is to bring at least 2cm of the distal esophagus below the hiatus. This dissection is carefully performed in a blunt fashion posteriorly, laterally and anteriorly when manipulating the esophagus with the umbilical tape. As shown here in patients with a long history of GERD, in this patient with a previous lung transplantation, it is typical to encounter denser adhesions laterally, which makes the dissection more difficult and may result in opening of the pleura. Extreme care is taken in this particular case to preserve the integrity of the pleura. We routinely carried out an extensive mediastinal dissection in order to mobilize completely the distal esophagus, but in this patient because of his previous lung surgery, the dissection is not carried out up to the level of the inferior pulmonary vein. Nonetheless, even with a less extensive mobilization, the GE junction seems to lie intra-abdominally. Although we routinely performed Nissen fundoplication even in patients with ineffective motility disorders, in this scleroderma case, we chose to perform a partial fundoplication. We believe that a good partial wrap will take care of reflux and prevent dysphagia in the setting of extremely poor peristalsis. Even though we are planning to build a partial posterior fundoplication, in order to build a floppy valve, the upper part of the fundus must be mobilized by dividing the short gastric vessels. This will allow for better geometry of the valve avoiding any esophageal kinking.
6. Partial fundoplication and general considerations 04'06''
The crura are then re-approximated with 2 non-absorbable sutures taking care not to overtighten the hiatus. The wrap is then fixed laterally to the esophagus and to the pylorus to firmly stabilize it intra-abdominally. A gastrograffin swallow was performed on the 1st postoperative day to confirm both the integrity and patency of the fundoplication. The patient was then allowed a soft diet and discharged on the 3rd postoperative day. At 3 months’ follow-up, the patient is doing well with complete resolution of GERD symptoms, dramatic reduction of the cough, and overall significant improvement of his respiratory function. Chronic allograft dysfunction after lung transplantation contributes to poor long-term survival. The link between gastric aspiration and post-transplant lung dysfunction has been suggested. GERD is prevalent in end-stage lung disease patients and it is even more common in patients after transplantation. In these patients mainly with IPF, reflux is associated with a hypertensive lower esophageal sphincter and abnormal esophageal peristalsis. After transplantation, other mechanisms could contribute to gastric reflux such as denervation of the lung, which could result in loss of cough and clearance with decreased mucociliary function. Lung transplant patients with severe GERD should be considered for anti-reflux surgery. Laparoscopic fundoplication can be performed safely in this patient population. In addition to the resolution of reflux symptoms, improvement in pulmonary function and prevention of complications is achieved.