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Nissen fundoplication (FDP) : Complete (360°) FDP
Toupet FDP : Partial (270°) FDP, posterior side
Belsey Mark IV repair: 240° FDP wrap around left lateral aspect
Nissen-Collis procedure creates "neoesophagus"
GE junction (at B ring) will be above diaphragm; intact wrap around proximal stomach (neoesophagus) will be below diaphragm
Preoperative: Identify "short esophagus," hiatal hernia, and dysmotility
Wrap complications
Tight FDP wrap (fixed narrowing and delayed emptying of esophagus)
Complete disruption of FDP sutures (recurrent hernia and reflux), partial disruption of FDP sutures (1 or more loose-looking outpouchings of wrap)
Intact wrap may slide downward over stomach; "hourglass" configuration of stomach
Intrathoracic migration of wrap upward through hiatus
Fluid collections in abdomen or mediastinum
Herniated abdominal fluid, lymph, hematoma, infection ± leak, abscess
Fluoroscopic esophagram soon after surgery is mandatory
Provides structural information, anatomical abnormalities
Wrap complications, leaks, persistence of reflux
CT for severe abdominal or chest pain, suspected visceral injury, or abscess
Incidence of complications is increasing as many laparoscopic FDPs are performed indiscriminately
Postoperative fluoroscopic evaluation should be used liberally or even routinely
CT for suspected leak or bleeding
Fundoplication (FDP)
Complications of antireflux surgery for management of gastroesophageal reflux disease (GERD)
Nissen FDP: Complete (360°) FDP
Approach: Laparoscopic or open FDP
Gastric fundus wrapped 360° around intraabdominal esophagus to create antireflux valve
Concomitant hiatal hernia is reduced; diaphragmatic esophageal hiatus sutured
Toupet FDP: Partial (270°) FDP
Posterior hemi valve created
Belsey Mark IV repair: Open surgical; 240° FDP wrap around left lateral aspect of distal esophagus
Fundus sutured to intraabdominal esophagus; acute esophagogastric junction angle (angle of His)
Can also be performed via minimally invasive techniques
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