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LAP Nissen Failures: Slipped Nissen or Missed Nissen?
Mustafa Abdul-Hussein*1, Onur Kutlu1, Donald O. Castell1, David Adams2
1gastroenterology and hepatology, medical university of south carolina, Charleston, SC; 2Surgery, Medical university of south carolina, Charleston, SC
INTRODUCTION: Gastroesophageal reflux disease (GERD) intractable to medical management is most commonly managed with laparoscopic Nissen fundoplication (LNF). After the adoption of a laparoscopic technique in 1991, the number of fundoplications performed in the United States increased initially, followed by a steady decline which was attributed to poorer than anticipated outcomes. The proper conduct of the LNF involves more than repair of a hiatal hernia. Elemental to the operative technique is mobilization of the mediastinal esophagus and restoration of normal intra-abdominal esophageal length. When these steps are bypassed the result is a gastro-gastric wrap wherein the gastric fundus in wrapped and plicated around the proximal stomach. Because a normal esophageal swallow leads to gastric contraction, the gastro-gastric wrap has untoward obstructive consequences that lead to poor outcomes.
METHODS: A retrospective review and analysis of patients who underwent revision of a gastro-gastric wrap (secondary surgery) at the Medical University of South Carolina over a two year period (August 2013 to September 2015) was undertaken. The interval from primary operation to the development of postoperative symptoms, the interval until secondary surgery, and esophageal radiographic and manometric prior to secondary surgery, operative findings, and early outcomes were determined.
RESULTS: Ten patients (7 women, 3 men), ages 35 to 59 (mean = 57.2) were identified who underwent repair of a gastro-gastric wrap after primary LNF in the community setting. The mean interval from primary to secondary operation was 52.7 months. The indications for the secondary operation were dysphagia (8), weight loss (3), heartburn (2), and regurgitation (4). Esophageal radiographic and manometric data recorded prior to secondary surgery is noted in Table 1. Duration of operation, operative findings, hospital length of stay, and operative morbidity are noted in Table 2. Operative mortality was zero.
CONCLUSIONS: Although slippage of the proximal stomach through the unbroken Nissen wrap creates a pouch below the diaphragm, the so-called slipped Nissen may more commonly be caused by incorrect placement of the wrap around the stomach. Radiographic interpretations frequently fail to properly characterize the gastro-gastric wrap. Dysphagia and weight loss are the hallmark of the untoward side effects of this wrap, and may occur early or late after the primary operation. Manometric findings are variable and characterized by features of IEM and achalasia. Secondary operations are lengthy and characterized by low complication rates and early resolution of dysphagia.
Table -1- Patients Demographics
| Total Number | 10 | | Sex | | | Male | 3 | | Female | 7 | | Age (mean) | 57.2 (35-69) | | Interval between procedures (mean) | 57.2 months (4-156) | | Indications | | | Dysphagia | 8 | | Weight loss | 3 | | Heartburn | 2 | | Regurgitation | 4 | | Duration of operation (mean) | 216 min (130-300) | | Intraoperative complications | 2 | | Post op stay (mean) | 1.5 days (0-4) | | | |
Table -2- Intra-operative Findings | patients | Interval between operations (months) | Duration of procedure (min) | post-op stay (days) | Findings | | 1 | 4 | 215 | 2 | Long gastro-gastric tight wrap. Paretic stomach, | | 2 | 29 | 156 | 2 | Intact gastro-gastric wrap, type II hiatal hernia. | | 3 | 35 | 175 | 2 | short esophagus. gastro-gastric wrap intact, hiatal hernia | | 4 | 48 | 130 | 2 | Type 3 hiatal hernia with fundus herniating posteriorly in mediastinum. Short esophagus | | 5 | 29 | 208 | 1 | Achalasia and intact gastro-gastric wrap. Converted to Toupet with myotomy | | 6 | 60 | 300 | 0 | Short esophagus. No previous esophageal mobilization. Complications: iatrogenic gastrotomy, primarily repaired | | 7 | 37 | 182 | 0 | Hiatal hernia. Intact gastro-gastric wrap with short intraabdominal esophagus | | 8 | 120 | 241 | 4 | paraesophageal hernia. Intact gastro-gastric wrap | | 9 | 156 | 260 | 1 | Hiatal hernia. Intact gastro-gastric wrap. Complications: iatrogenic gastrotomy. primarily repaired | | 10 | 9 | 294 | 1 | Paraesophageal hernia. Intact gastro-gastric wrap |
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