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Fundoplication and Other Antireflux Procedures


KEY FACTS

Terminology

  • 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

Imaging

  • 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

Clinical Issues

  • Incidence of complications is increasing as many laparoscopic FDPs are performed indiscriminately

Diagnostic Checklist

  • Postoperative fluoroscopic evaluation should be used liberally or even routinely

  • CT for suspected leak or bleeding

Graphic shows a Nissen fundoplication (FDP) with the gastric fundus wrapped completely (360°) around the gastroesophageal junction.

Upright spot film from an esophagram performed soon after a Nissen FDP shows an intact wrap
in its expected subdiaphragmatic location as a filling defect within the air-filled fundus. The distal 3 cm of the esophageal lumen is compressed
as it passes through the wrap.

A supine film from the same study shows the intact wrap
as a filling defect with the barium pool in the fundus.

Axial NECT shows an intact FDP as a soft tissue density mass
within the gastric fundus. The metallic staple line is evident within the wrap. The mass effect of the wrap tends to decrease with time following surgery.

TERMINOLOGY

Abbreviations

  • Fundoplication (FDP)

Definitions

  • 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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