Unusual cause of new onset persistent dysphagia after Nissen fundoplication

Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.

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Unusual   cause   of   new   onset   persistent   dysphagia   after   Nissen   fundoplication

Authors
B Dallemagne, J Marescaux
Abstract
Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.
Classification
clinical cases
Keywords
Unusual cause, new onset persistent dysphagia after Nissen fundoplication
Media type
Duration
16'30''
Publication
2009-07
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E-publication
WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2662.htm

Unusual   cause   of   new   onset   persistent   dysphagia   after   Nissen   fundoplication

1. Clinical case presentation 00'08''
This video presents quite a complex case of persistent dysphagia after a laparoscopic Nissen fundoplication. In fact, this is the case of a patient who had a Nissen fundoplication back in 1995 for a documented GERD. Since this surgery, the patient developed major complaints with persistent dysphagia, a lot of retrosternal pain and food regurgitation. During this 13-year period, she had different exams and of course, manometric studies (6 in total) that did not demonstrate an esophageal peristalsis problem. The LES was functioning properly, with a good relaxation; there were no signs of acid reflux and the patient did not complain of heartburn. On the barium swallow made in 2001, there is a twisted shape of the junction of the lower part of the esophagus crossing the diaphragm and there was also a suspicion that part of the fundoplication was above the diaphragm. This patient has had 10 endoscopic dilations without any clinical improvement, and in 2009 she was referred to our department. On this X-ray, we can effectively see that there is a twist where the esophagus crosses the diaphragm, and we can also see a bubble of the fundoplication above the diaphragm. This is a laparoscopic approach. The patient had a previous laparoscopic surgery so there is no risk of adhesions as the ones we can see after an open fundoplication. The trocars are placed in a conventional fashion; it is a 5 trocar approach and for this redo surgery, we are used to working with scissors, because we have the feeling that scissors respect the different cleavage planes well and allow a more accurate identification of the previous planes.
2. Identification of landmarks 02'40''
The goal of the first part of the operation is to restore the different landmarks of this area, to find the crus, both right and left, to localize the esophagus and the GE junction and usually when you have reached this point, you can have an idea of the patient’s problem. During this part of the operation, we can see on the left diaphragm that there are very unusual adhesions of the gastric fundus on the diaphragm with a muscular structure between the esophagus and the gastric fundus, which is not the usual aspect of a fundoplication on the left side of the esophagus. We also observe a fundoplication with the left part of the valve, which is clearly viewed. Guidance is provided by the previous suture material and we follow it to open the fundoplication in its middle part, and so we have dismantled the left part of the anti-reflux mechanism. At this point, we have not yet clearly identified the right part of the fundoplication. This is the left part of the fundoplication and we see that the gastric fundus passes behind the esophagus but we don’t know where the right part of the fundoplication is. We go back to the mediastinum trying to identify the right and left borders of the esophagus. We can see in this area that there is something wrong with the right side of the esophagus, which probably corresponds to the radiological image with gastric compartment above the diaphragm. To be sure that we restore the landmarks, we go to the right crus and try to follow its margin. Again, we are moving to the mediastinum to identify the right border of the lower esophagus and the cardia. But again, the dissection of this plane is not easy, the usual dissection planes are not easily found and we can see that there is something wrong on the right side. If we want to get the right part of the esophagus, we have to go a little bit higher into the mediastinum. The right crus is identified in part of these structures; following the inner side of this right crus, again we are trying to find the right border of the esophagus but there are some gastric tissues that lie in the middle of this plane, which is totally unusual. So we initially suspect an intra-mediastinal herniation of the right part of the valve, because we found this right part within the mediastinum. No clear view on the lower part of the right crus, so we move back to the left crus to understand why we have this aspect. And again, we can see that there is a problem with the gastric fundus, which is going in towards the diaphragm, and not towards the lower part of the esophagus.
4. Dismantling of fundoplication 10'30''
At this point, the only solution is to dismantle all this mechanism. During this dissection, the cleavage planes are difficult to find, we had a small injury on the gastric fundus. We can see the valve crossing the diaphragm and not the retro-esophageal window and we have to detach this valve from the esophagus. Of course, at this point the risk of esophageal injury is high, so we usually prefer to work on the gastric side instead of the esophageal side because we know that when we have an injury of the gastric wall, it is much easier to repair than if we have one on the esophageal wall, so that we favour a gastric injury to an esophageal injury. Once we have totally mobilized this right part of the fundoplication, we will pass it back through the wrong route to place it in a normal position. The discussion is now if we should add a new anti-reflux mechanism in this patient with a long history of dysphagia and chest pain. We now all know that the risk of re-fundoplication is dysphagia, even very slight dysphagia, but usually these patients have been almost destroyed by these problems during a long period of time, so we decided to avoid any risk of dysphagia and we decided to dismantle all the anti-reflux mechanism and not to reconstruct any new anti-reflux repair. We can see the left crus on this view and the hole through which the fundoplication was passed. This surgical mistake highlights the necessity of having and maintaining surgical vision through the laparoscope. It also illustrates the need for clear anatomical landmarks because it is a very nice demonstration of wrong anatomical landmarks, and what we have seen on the preoperative X-rays is that there were a lot of clips in this area, so probably the first surgeon had bleeding problems, bleeding because of the wrong route through the muscle. Bleeding will lead to the loss of landmarks and finally we end up with this sort of misrouting of the gastric fundus and this unsuited creation of a good anti-reflux mechanism. The perforation of the gastric fundus is repaired with an absorbable running suture. Usually, this sort of injury does not lead to any postoperative problems; that was the case in this patient with an uneventful postoperative outcome. The main symptoms such as chest pain and major dysphagia disappeared quite quickly; she still complained of upper GI discomfort. As a routine, we perform a gastrograffin swallow on the first day after surgery. This study demonstrated that the twist of the lower esophagus had disappeared, that the sphincter opened quite easily with good relaxation and that the liquid bolus transits very easily through the GE junction. Of course, we didn’t have any anti-reflux mechanism and from the first day after the surgery, the patient was placed under PPI. The patient was aware of this possibility when we discussed the different options of the treatment preoperatively and we had mentioned that probably because of these very important symptoms, we would end without an anti-reflux mechanism. So it’s important to discuss this with the patient and explain exactly what we are planning to do, even if in some circumstances it is difficult to plan for the peroperative or the intraoperative findings.