Postsurgical Endoscopic Anatomy

Nissen Fundoplication

Fundoplication is an effective antireflux operation, performed by creating a gastric plication over the distal esophagus just proximal to the cardioesophageal junction to restore the competency of lower esophageal sphincter. This is a standard operative treatment in select patients with gastroesophageal reflux disease (GERD) ( Fig. 12.1 ).

Fundoplication was first described by Dr. Rudolph Nissen in 1955. This procedure is frequently performed along with hiatal hernia surgery. A modified technique called a floppy Nissen fundoplication can be accomplished by shortening the wrap from 5 cm to 2 cm. Despite being more lax than a conventional Nissen fundoplication, it is equally effective for GERD management, with the additional benefit of a lower incidence of postoperative gas-bloat syndrome or dysphagia. A laparoscopic approach to this procedure has proved to be safe and reliable. Laparoscopic floppy Nissen fundoplication has become the surgical gold standard treatment for GERD.

To perform Nissen surgery, the distal esophagus, the cardioesophageal junction, the gastric fundus, and the right and left crura are dissected. Careful dissection is required to avoid transection of the nerve of Latarjet, a branch of anterior vagal trunk supplying the pylorus. Damage to this branch can result in delayed gastric emptying. After hernia reduction, the right and left crura are approximated with sutures (see Fig. 12.1A ). Division of the short gastric vessels may be required to mobilize the fundus. The gastric fundus is mobilized posterior to the cardioesophageal junction, creating a 360-degree wrap by the placement of two or three sutures involving stomach-esophagus-stomach in the anterior portion of the wrap (see Fig. 12.1B1 ). The anterior and posterior vagus nerves are usually contained in the wrap and attached to the esophagus. At the end of the procedure, the wrap must lie below the diaphragm without tension.

During endoscopy, an intact Nissen fundoplication is easily identifiable. During antegrade endoscope passage, the gastroesophageal junction appears tight on visualization, but offers mild resistance to passage of the endoscope. The retroflexed view reveals an encircling redundant mucosa with several parallel rugal folds overlying the gastric cardia, as well as less capacious stomach fundus (see Figs. 12.1B2 ). Although this is a 360-degreee wrap, the redundant fold appears as a 270-degree free cuff margin because the border continuous with the lesser curvature is not evident. The crural closure should maintain the cardia below the diaphragm with the stomach completely insufflated with air. Occasionally, sutures in the distal esophagus may be observed, indicating migration through the wall or inappropriate penetration depth of the stitches during the procedure; this may or may not be associated with symptoms.

Findings associated with failure of the fundoplication include esophagitis, lack of the encircling fold on a retroflexed view, patulous gastroesophageal junction, migration of the wrap through an enlarged esophageal hiatus, or hourglass appearance of the proximal stomach (indicating slippage and irregularity in the dome shape of the fundus, which in turn indicates parahiatal hernia). A squamocolumnar junction located more than 1 cm proximal to the margin of the wrap has been reported to be a major endoscopic clue in diagnosis of postfundoplication problems. An upper GI contrast study can delineate the precise relationship between the wrap and diaphragmatic hiatus when endoscopic examination is unable to clarify if the wrap is intact. Gastric food retention secondary to gastroparesis may be related to damage to the vagus nerves during the procedure. Some patients with persistent dysphagia have a tight wrap that causes resistance to the advancement of the endoscope and these patients may benefit from endoscopic dilation.

Partial Fundoplications (Dor and Toupet)

A partial fundoplication is created with the fundus partially enveloping the distal esophagus, enabling a reduction in postoperative dysphagia and gas-related side effects. A Dor fundoplication is performed anteriorly, and is usually performed in patients who also require a Heller myotomy (see Fig. 12.1C ). Toupet fundoplication is performed posteriorly and is best indicated in patients with impaired esophageal body motility (see Fig. 12.1D ). Partial fundoplications also have a prominent fold overlying the cardia, which is less evident than 360-degree wraps when observed endoscopically.

Belsey Mark IV

The Belsey Mark IV fundoplication requires a thoracotomy. A partial 240-degree anterior wrap is created by the placement of three sutures involving stomach fundus and distal esophagus, resulting in a progressive invagination of the esophagus into the proximal stomach. The crura are also sutured to narrow the esophageal hiatus (see Fig. 12.1E ). Endoscopically, the Belsey Mark IV and Nissen fundoplications appear similar, with folds encircling the endoscope at the level of the cardia. However, coils of gastric rugae as seen after Nissen repair are not evident, and there is an anterior compression that corresponds to the attachment of the esophagus to the diaphragm.

Collis Gastroplasty

A short esophagus, usually caused by chronic scarring resulting from GERD, can be repaired surgically through a Collis gastroplasty. This gastroplasty creates a tubular segment of stomach in continuity to the esophagus, long enough to be encircled by a 360-degree fundoplication placed below the diaphragm. The fundoplication around this tubular segment within the positive pressure of the abdomen prevents the gastroesophageal reflux. Short esophagus is identified less often presently, because GERD is diagnosed and treated earlier, reducing the incidence of esophageal scarring and shortening. Endoscopically, the squamocolumnar junction is observed above a short tubular segment of stomach, which may not distend properly because of the wrap. The Collis gastroplasty resembles the Nissen fundoplication on a retroflexed view, except with a less capacious fundus.

Billroth I

The Billroth I operation is a type of reconstruction after a partial gastrectomy in which the stomach is anastomosed to the duodenum ( Fig. 12.2A ). The gastric resection is usually limited to the antrum, and a truncal vagotomy is often performed in conjunction with the resection. The gastroduodenostomy anastomosis is found toward the greater curvature. A prominent gastric fold representing the closed part of the stomach is often observed along the lesser curvature ending at the gastroduodenostomy. A mucosal pattern change from gastric folds to flat duodenal surface indicates the anastomosis site. The duodenal bulb is partially resected, and the circular folds of the second portion are visualized endoscopically immediately distal to the anastomosis. Major and minor papillae appear to be more proximal in the duodenum than in a patient with intact anatomy. Following the loss of the pylorus, bile reflux is very commonly seen.