1. Treating Complications Dysphagia, Leaks, Gastric Dysfunction Following Nissen Fundoplication Brant K. Oelschlager, MD University of Washington

2. CENTER FOR VIDEOENDOSCOPIC SURGERY

3. Postoperative Dysphagia 288 patients with 5 year follow-up 7 patients (2%) developed new dysphagia

4. CENTER FOR VIDEOENDOSCOPIC SURGERY Dysphagia Early versus Late

5. CENTER FOR VIDEOENDOSCOPIC SURGERY Dysphagia  Incidence  Before Nissen – 43%  78% improved or resolved with Nissen  New onset Dysphagia - 2%  (Oelschlager BK, Am J Gastro 2007;102:1)  Causes  Technical/anatomic factors  Esophageal dysmotility

6. CENTER FOR VIDEOENDOSCOPIC SURGERY Dysphagia  Avoidance  Proper operative technique  Control of GERD  Proper work-up  Pre-operative Counseling  Treatment  Supportive 3-4 months  Dilation if persists  Look hard for anatomic problems  If all fails and no anatomic problem, revise to partial fundoplication

7. CENTER FOR VIDEOENDOSCOPIC SURGERY Early Post-Operative Dysphagia  UGI or Endoscopy to r/o anatomic problem  Patient tolerating liquids and can nourish and hydrate  In first 8-12 weeks – patience  More severe or more than 12 weeks  Investigate further  Consider dilation

8. CENTER FOR VIDEOENDOSCOPIC SURGERY Causes of Dysphagia  Recurrent Hiatal Hernia  Too Tight  Incorrect Orientation  Motility  Normal Post-operative Dysphagia

9. CENTER FOR VIDEOENDOSCOPIC SURGERY Type IA Hernia GERD Occasionally Dysphagia The Gastroesophageal Junction and the Wrap are Above the Diaphragm

10. CENTER FOR VIDEOENDOSCOPIC SURGERY Recurrent Hiatal Hernia  Acute herniation (first 7-10 days) should be treated with emergent operation  Others present more insidiously and can usually be managed electively

11. CENTER FOR VIDEOENDOSCOPIC SURGERY Causes of Recurrent Hiatal Hernia  Large Hiatal Hernia  Poor Closure  Short Esophagus  Obesity

12. CENTER FOR VIDEOENDOSCOPIC SURGERY Biologic Mesh Reinforced Repair

13. CENTER FOR VIDEOENDOSCOPIC SURGERY Recurrence Rate 24% 9%* * p = 0.04 Primary SIS UGI 6 Months After LPEHR

14. CENTER FOR VIDEOENDOSCOPIC SURGERY Short Esophagus Sandone C. Ann Surg. 2000; 232:630-40 Collis Gastroplasty

15. CENTER FOR VIDEOENDOSCOPIC SURGERY Short Esophagus Terry M. Am J Surg 2004; 188:195-99 Wedge Gastroplasty

16. CENTER FOR VIDEOENDOSCOPIC SURGERY Obesity & Antireflux Surgery Normal Overweight Obese n (%)n (%)n (%) Recurrence4 (5%)7 (8%)15 (31%) No Recurrence85 (95%)80 (92%) 33 (69%)* † * P = 0.001 vs. obese † p < 0.0001 vs. normal Perez AR, Surg Endosc 2002;16:1380.

17. CENTER FOR VIDEOENDOSCOPIC SURGERY Obesity & Antireflux Surgery Morgenthal CB. Surg Endosc 2007.

18. CENTER FOR VIDEOENDOSCOPIC SURGERY Obesity and Antireflux Surgery Anvari M, Surg Endosc 2006,20:230

19. CENTER FOR VIDEOENDOSCOPIC SURGERY Malpositioning

20. CENTER FOR VIDEOENDOSCOPIC SURGERY Fundoplication Too Tight Technique Dilate, but wait if possible

21. CENTER FOR VIDEOENDOSCOPIC SURGERY Type II Hernia GERD Dysphagia or Both Paraesophageal Hernia

22. CENTER FOR VIDEOENDOSCOPIC SURGERY Type III Hernia Dysphagia Occasionally GERD Malformation of the wrap. The body of the stomach is used to perform the fundoplication.

23. CENTER FOR VIDEOENDOSCOPIC SURGERY

24. Proper Grasp for Fundoplication

25. CENTER FOR VIDEOENDOSCOPIC SURGERY (Video showing correct technique)

26. CENTER FOR VIDEOENDOSCOPIC SURGERY Symmetrical Repair

27. CENTER FOR VIDEOENDOSCOPIC SURGERY Non-Symmetrical Nissen

28. CENTER FOR VIDEOENDOSCOPIC SURGERY Motility Disorders  Important to diagnose underlying primary disorders pre-op  If primary disorder found post-op treat accordingly ** (Pic of Achalasia tracing)

29. CENTER FOR VIDEOENDOSCOPIC SURGERY Motility Disorders  Wait, Patience, Wait  Dilate  Revise to a Partial Fundoplication Tracing of IEM

30. CENTER FOR VIDEOENDOSCOPIC SURGERY Dysphagia and Normal Anatomy & Function  Wait  Patience  Wait  Dilate  Wait  Revise to a Partial Fundoplication

31. CENTER FOR VIDEOENDOSCOPIC SURGERY Management of Esophageal Leaks  Recognition  Diagnosis  Treatment

32. CENTER FOR VIDEOENDOSCOPIC SURGERY Recognition  Triad of Symptom – though rarely all three present until late  Chest Pain  Persistent vomiting  Sub-q emphysema  Non-iatrogenic perforations picked up late because diagnosis often not considered early  Three important things to note that drive management  Location  Underlying cause  Time from insult to intervention

33. CENTER FOR VIDEOENDOSCOPIC SURGERY Diagnosis  CXR  Can increase suspicion, but can’t rule in/out  UGI (best test)  Diagnosis, severity, location  CT (being used more frequently)  If can’t do UGI (Intubated, etc)  Direct non-operative management  EGD (rarely)  Maybe for management?

34. CENTER FOR VIDEOENDOSCOPIC SURGERY Treatment of Post-Surgical Leaks  Small, contained leaks  Antibiotics +/- drain and wait  Leaks occurring and recognized in the first 24 - 48 hours  Consider laparoscopic reoperation, primary closure and buttress  Late occurring

35. CENTER FOR VIDEOENDOSCOPIC SURGERY Self-Expanding Plastic Stent(SEPS)  Similar to SEMS in Concept  Radial Expansile Force Less than SEMS  Causes Less Trauma than SEMS  Can be Repositioned or Removed  Indications:  Refractory benign and malignant strictures  Intrinsic or extrinsic lesions  Esophageal-respiratory fistula Polyflex®

36. CENTER FOR VIDEOENDOSCOPIC SURGERY Results Clinical OutcomeNo. pts Relief of dysphagia allowing oral feeding27/39 (69%) Sealing of esophageal leakage11/15 (73%) Stent dysfunction6/39 (15%) Stent migration8/39 (20%) Re-intervention14/39(36%) Stent removal b/o intolerability5/39 (13%) Radecke et al. Gastrointest Endosc 2005; 61:812-818

37. CENTER FOR VIDEOENDOSCOPIC SURGERY Endoscopic Therapy Metallic StentsPlastic Stents Role still evolving Possibly for large leak effectively drained No control studies - don’t know denominator or how many would heal on their own

38. CENTER FOR VIDEOENDOSCOPIC SURGERY Gastric Dysfunction

39. CENTER FOR VIDEOENDOSCOPIC SURGERY 28 patients (<10%) develop new bloating Bloating/Gastric Dysfunction Bloating severity postop Now compared to before operation Better (n=69) Worse (n=78) Same (n=41)

40. CENTER FOR VIDEOENDOSCOPIC SURGERY Bloating  Incidence  18% before surgery 12% after surgery (Oelschlager BK, Am J Gastro 2007;102:1)  19% after (Klaus A, Am J Med 2003;114:6.)  Causes  Underlying gastroparesis  Air swallowing  Vagal nerve injury  Associated IBS (~66%) and overlapping GI diseases

41. CENTER FOR VIDEOENDOSCOPIC SURGERY Bloating  Avoidance  Avoid Vagal trauma (Including nerve of Laterjet)  Pre-operative Counseling  Beware of associated IBS  Treatment  Recognition  Supportive  Rarely, if ever, perform surgical gastric emptying  Endoscopic pyloric dilation or Botox  Potentially convert to partial fundoplication

42. CENTER FOR VIDEOENDOSCOPIC SURGERY The Role of Pre-op Gastric Emptying Studies

43. CENTER FOR VIDEOENDOSCOPIC SURGERY Improvement in Gastric Emptying with Fundoplication

44. CENTER FOR VIDEOENDOSCOPIC SURGERY Effectiveness of Empyting Procedures for Gastroparesis

45. CENTER FOR VIDEOENDOSCOPIC SURGERY Copyright restrictions may apply. Watson, D. I. et al. Arch Surg 2004;139:1160-1167. Less Bloating with Partial Fundoplication?

46. CENTER FOR VIDEOENDOSCOPIC SURGERY Strategy Post-op Gastric Dysfunction  Based on Severity  Work-up  Gastric Emptying – documentation  UGI – Function and fundoplication anatomy  Manometry – associated motor disorders  24-hour pH - ? Reflux control  Options  Emptying Procedure  Partial Fundoplication  Gastrectomy

47. CENTER FOR VIDEOENDOSCOPIC SURGERY “Before we consider assisted suicide, Mrs. Jones, let’s give the Prilosec a chance”