Complications of Intrathoraac Nissen Fundoplication

Complications of Intrathoraac Nissen Fundoplication Kamal A. Mansour, M.D., Harry G. Burton, M.D., Joseph I. Miller, Jr., M.D., and Charles R. Hatcher, Jr., M.D. ABSTRACT This report details our experience with 30 patients who had Nissen fundoplication. Six underwent transabdominal Nissen fundoplication, and 10 had transthoracic Collis-Nissen with the gastric wrap in a subdiaphragmatic position. Ten patients had a transthoracic Nissen with the wrap in a supradiaphragmatic position. Four patients had a transthoracic Thal-Nissen procedure. In 1 of 4 patients with a Thal-Nissen procedure, intrathoracic rupture of the stomach with gastrobronchial fistula developed and necessitated left lower lobectomy. Four of 10 patients in whom the gastric wrap was left in the chest experienced severe complications: in 1 patient a lesser mature ulcer developed and required hemigastrectomy; 1 patient had herniation of the fundoplication with gastric outlet obstruction and required operation for its correction; 2 patients had intrathoracic rupture of the gastric wrap and ultimately died. The 6 patients with transabdominal Nissen and the 10 with transthoracic Collis-Nissen with wrap placed in the abdomen did well. This experience severely condemns the practice of leaving the fundoplication above the diaphragm. Since 1951 when Allison [l] recommended reflux prevention as a goal of hiatal hernia operation, the focus of attention has been on improving operative morbidity and reducing the recurrence of reflux and associated sequelae. The most frequently utilized techniques are those popularized by Nissen, Belsey, and Hill. Of these, the Nissen fundoplication is quoted as having the lowest morbidity and recurrence rate and is probably the most common antireflux procedure performed today [la, 21. From the Division of Cardio-Thoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA. Presented at the Twenty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Nov 13-15, 1980, White Sulphur Springs, WV. Address reprint requests to Dr. Mansour, Emory University Clinic, 1365 Clifton Road NE, Atlanta, GA 30322. In 1937, Nissen [3] reported a successful transpleural resection of the cardia in a patient with a perforating peptic ulcer. The mobilized lower esophagus was implanted in the stomach in the same fashion as a rubber tube is implanted in a Witzel gastrostomy. The patient was subsequently noted to be free from reflux symptoms years after the operation. This led to the introduction of the gastric fundoplication by Nissen in 1955. In this repair, a left subcostal incision is employed and the lesser omentum opened. The anterior and posterior fundal folds are sutured to the anterior esophageal wall over a large bougie in the esophagus. Later the procedure was simplified, and the risk of injury to the anterior vagus nerve was eliminated. A cuff is fashioned exclusively from a mobile fundal fold of the anterior gastric wall by dividing the short gastric and left gastroepiploic vessels. Then the fundus is passed posterior to the esophagus so as to wrap it around the lower esophagus. The two enfolding portions of the fundus are approximated by interrupted sutures exterior to the esophageal wall. This modification of fundoplication is technically easier, safer, and more effective. One reason for the popularity of the Nissen procedure has been the easy accessibility to either the transabdominal or transthoracic approach. The advantage of the abdominal approach is emphasized by Krupp and Rossetti [4], and it is the most commonly used approach. The transthoracic approach is usually reserved for patients with chronic ulceration of the cardia, cicatricial stenosis, shortening of the esophagus, recurrent hernia, severe periesophagitis, or extreme obesity or when carcinoma is suspected. Kent and Gompels [5] treated strictures of the esophagus with the Nissen fundoplication deliberately left in the chest. Nicholson and Nohl-Oser [61 reported a large series of patients in whom the Nissen wrap was left in the chest. The patients had reflux esophagitis, and the fibrosed esophagus could not be mobilized 173 0003-4975/81/080173-06!$01.25 @ 1981 by The Society of Thoracic Surgeons

174 The Annals of Thoracic Surgery Vol 32 No 2 August 1981 sufficiently to allow an intrabdominal procedure to be performed. These authors also have used this technique in the chest in conjunction with longitudinal incision and transverse closure of tight, short strictures in elderly patients who could not have tolerated esophageal resection, and found it to give very satisfactory results. Woodward and colleagues [7] stated that, in their hands, the transthoracic Nissen fundoplication with the repair left above the diaphragm has provided excellent results in surgical management of patients with recurrent reflux esophagitis and acquired shortening of the esophagus. The purpose of this paper is to review our experience with Nissen fundoplication and to emphasize the serious complications that can occur when the gastric wrap is left in the chest. Material and Methods Between July, 1971, and July, 1980,201 patients underwent operation for reflux esophagitis at Emory University Hospital. One hundred seventy-one of these patients underwent the Mark IV operation, and Nissen fundoplication was performed in 30 patients. Of the 30 patients, transabdominal Nissen was performed in 6, transthoracic Collis-Nissen with subdiaphragmatic gastric wrap in 10, transthoracic supradiaphragmatic gastric wrap in 10, and transthoracic Thal-Nissen in 4. Patients with a transabdominal Nissen and those with a transthoracic Collis-Nissen with the wrap placed in the abdomen did well. Complications of serious magnitude occurred in 5 patients who underwent a transthoracic Nissen with the gastric wrap left in the chest. In 1 patient, a lesser curvature ulcer developed just distal to the wrap. He was managed medically but ultimately required a hemigastrectomy. In 1 patient, gastric herniation with outlet obstruction developed at the diaphragmatic level and necessitated further operation. Another patient sustained an intrathoracic rupture of the gastric wrap with the development of a gastrobronchial fistula. A left lower lobectomy was done. Two patients had intrathoracic gastric rupture and ultimately died. Fig I. (Patient I,) Barium swallow showing a lesser curvature gastric ulcer just below the intrathoracic Nissen wrap. Case Reports PATIENT 1. A 58-year-old woman was admitted to the hospital because of dysphagia. Past history included an abdominal Nissen fundoplication for reflux esophagitis and a distal esophageal stricture eighteen months prior to admission. She had done well for approximately two months but then increasing dysphagia developed. A barium swallow and esophagoscopy demonstrated recurrent hernia and free reflux. Esophageal dilation and conversion of the abdominal Nissen to a thoracic Nissen fundoplication were performed. Symptoms alleviated but esophagoscopy eight months later showed a lesser curvature gastric ulcer just below the wrap (Fig 1). The patient was placed on antacid therapy, and follow-up endoscopy has shown

175 Mansour et al: Intrathoracic Nissen Fundoplication Fig 2. (Patient 2.) Barium swallow showing herniation of an intrathoracic gastric wrap in the right chest with obstruction at the level of the diaphragm. healing of the ulcer. Five years later the patient was admitted with upper gastrointestinal (GI) bleeding. She was found to have a gastric ulcer and underwent excisional biopsy, primary closure, and hemigastrectomy. Since then she has done quite well. PATIENT 2. A 59-year-old man was admitted to the hospital with a one and one-half year history of dysphagia and symptoms of reflux esophagitis. Cineesophagogram showed a sliding hiatus hernia with moderate stricture and free gastroesophageal reflux. Esophagoscopy and biopsy revealed ulcerative esophagitis. The patient underwent transgastric biopsy of the mucosal ulceration followed by esophageal dilation and a Nissen fundoplication. A barium swallow one week postoperatively showed no obstruction, and the patient was discharged on the tenth postoperative day. Two months following discharge, the patient was seen again for epigastric pain and vomiting. Barium swallow showed herniation of the gastric wrap in the right chest with obstruction at the level of the diaphragm (Fig 2). Right tho- racotomy and exploratory laparotomy were performed, and the stomach was reduced below the diaphragm. The gastric wrap was sutured to the mediastinal pleura. Recovery was uneventful. PATIENT 3. A 58-year-old textile worker with a six-year history of dysphagia was admitted to the hospital. Barium swallow and esophagoscopy showed a sliding hiatus hernia with distal esophageal stricture. A Thal-Nissen procedure was performed, and follow-up barium swallow on the fifth postoperative day showed no reflux, obstruction, or extravasation. On the seventh postoperative day, a large left pneumothorax was diagnosed by roentgenogram. Hypaque (diatrizoate sodium) swallow confirmed stomach perforation. Exploration and conversion of the perforation to a gastrostomy were done. The patient had an uneventful recovery. Seven months later he was readmitted for evaluation of cough related to intake of food, and barium swallow demonstrated a left gastrobronchial fistula (Fig 3). The fistula was repaired by ligation and oversewing of the stomach perforation. Ten months later the patient was readmitted with recurrence of gastrobronchial fistula. A left lower lobectomy and closure of the gastric fistula were accomplished through the same thoracotomy incision. Recovery was uneventful. PATIENT 4. A 72-year-old woman was admitted to the hospital with dysphagia, heartburn, and frequent vomiting of six months duration. Upper GI series and esophagoscopy demonstrated a sliding hiatus hernia, a Schatzki s ring, and multiple small superficial ulcerations of the distal esophagus. Transgastric excision of Schatzki s ring and Nissen fundaplication were performed in the chest. On the seventh postoperative day sudden respiratory distress was noted, and the patient was found to have a left tension pneumothorax. A chest tube was inserted, and emergency operation revealed a perforation of the stomach in the area of the wrap. This was closed primarily, and a double-barrel jejunostomy was created transabdominally. The patient did well for seven days but then had recurrence of the gastric perforation. It was closed again, and a gas-

176 The Annals of Thoracic Surgery Vol 32 No 2 August 1981 Fig 4. (Patient 5.) Barium swallow demonstrating a right gastropleural fistula on the fifth postoperative day. Fig 3. (Patient 3.) Barium swallow demonstrating a left gastrobronchial fistula. trostomy was performed. Subsequently she sustained a cerebrovascular accident and died. PATIENT 5. A 77-year-old woman had undergone transabdominal Nissen fundoplication five years prior to admission. For the past three years she had experienced increasing dysphagia. Upper GI series and esophagoscopy showed recurrent hiatus hernia and ulcerative esophagitis. The patient underwent intrathoracic Nissen fundoplication. The previously incised hiatus was closed loosely around the fundic wrap, and the latter was tacked to the diaphragm to prevent herniation. Chest roentgenogram five days later showed a large right hydropneumothorax, and barium swallow confirmed a leakage from the gastric wrap (Fig 4). A chest tube was inserted converting the leak to a controlled fistula, and the patient was treated with parenteral hyperalimentation and nasogastric suction. An upper GI series two weeks later demonstrated the fistula had closed (Fig 5), and the tube was converted to open drainage. The patient was discharged. Two months following operation, the patient died suddenly at home. Postmortem examination showed a right pleural empyema and a tract leading from the gastric wrap into the pericardial cavity with an area of ulceration on the posterior aspect of the left ventricle. Comment Transthoracic Nissen fundoplication, when properly performed, is an effective operation in preventing reflux in at least 90% of the patients in whom it is done. Care should be taken, however, to mobilize the esophagus sufficiently to restore a satisfactory intraabdominal segment. If the esophagus is foreshortened, a Collis gastroplasty should be added so that the gastric wrap can be brought into the abdomen. The gastric wrap should be performed over a large bougie to avoid excessive narrowing of the

177 Mansour et al: Intrathoracic Nissen Fundoplication Fig 5. (Patient 5.) Barium swallow demonstrating closure of the fistula two weeks later. distal esophageal segment. Care should be taken to preserve the vagus nerves and avoid axial rotation of the wrap. The counterincision in the diaphragm should be carefully closed using nonabsorbable sutures and including both pleural and peritoneal surfaces. Care should also be exercised to avoid too tight a crural closure. Certain complications are inherent to the Nissen fundoplication. The gastric wrap may slip, partially or totally disrupt, obstruct, or become incompetent. The gastric mucosa may intussuscept, ulcerate, or perforate. Gastric ulcers situated in the middle of the lesser curvature or in the antrum have been reported after Nissen fundoplication. Bremner [8] thought alkaline gastric reflux was responsible because his 4 patients had hypochlorhydria and atrophic gastritis. Bushkin and colleagues [9] considered the cause to be gastrin hypersecretion secondary to gaseous distention, but gave no supporting evidence. Among the complications of fundoplication, Burnett and associates [la] reported a high lesser curve ulcer, which they accepted as an operative complication without comment. Inadvertent division of the vagal fibers of the cardia might theoretically lead to gastric stasis and predispose to ulcer formation. Scobie [lo] reported three gastric ulcers occurring near the cardia and postulated that mechanical factors related to the operative procedure may be relevant. The creation of a fundoplication causes angulation of the lesser curvature possibly leading to local pressure and venous congestion; devascularization of the cardioesophageal area may result during mobilization of the fundus to create the wrap; or seromuscular sutures to anchor the wrap to the diaphragm may pull off and cause gastric leak. Balison and associates [lll reported the cases of 5 patients with diaphragmatic hernia following transthoracic fundoplication. They developed either through the diaphragmatic counterincision or through the hiatal closure or both. Incarceration and symptomatic partial obstruction were associated with volvulus of the supradiaphragmatic portion of the stomach in 4 patients, and 1 patient had partial obstruction of a herniated splenic flexure of the colon. In order to obviate the upward displacement of the repair and reduce the recurrence rate, Cordiano and associates [12] modified their technique by anchoring the fundoplication to the right crus of the diaphragm. The cause of the gastric rupture in our series is not definitely known. It may be related to marked distention of the gastric wrap subjected to the negative intrathoracic pressure. There was no known compromise of the blood supply to the gastric wrap. There was no evidence of tissue necrosis at the site of the perforation. Care was taken to avoid a tight wrap and a tight hiatal closure. A noted characteristic of these gastric ruptures is their recurrence after surgical repair or apparent spontaneous closure. Krupp and Rossetti [4] reported two gastric fistulas in the region of the fundoplication that healed spontaneously. There were 4 deaths after abdominal fundoplication in their reported series of 524 patients, 3 due to perforating peritonitis and 1 arising from a ruptured peptic ulcer overlooked at operation. The mortality of their transthoracic operations was 16.7'/0 (5

178 The Annals of Thoracic Surgery Vol 32 No 2 August 1981 out of 30), with 2 deaths due to a fistula in the region of the fundoplication. Ikard and Jacobs [13] reported a case of fundoplication complicated by subphrenic abscess and gastropericardial fistula. Burnett and colleagues [ll published a startling list of complications from fundoplication. In 50 transabdominal Nissen procedures, there was 1 patient with gastric leak, and in 18 transthoracic fundoplications, there were 5 patients with leaks (28%), 3 of whom died. It is evident from this review that intrathoracic Nissen wrap is subject to potentially lethal complications in the form of gastropleural, gastrobronchial, and gastropericardial fistula formation. This report further substantiates that leaving the wrap in the chest is hazardous and should be severely condemned. References 1. Allison PR: Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet 92:149, 1951 la. Burnett HF, Read RC, Morris WD, Campbell GS: Management of complications of fundopli- 3. Nissen R: Transpleural resection of the cardia. Dtsch Z Chir 249:311, 1937 4. Krupp S, Rossetti M: Surgical treatment of hiatal hernias by fundoplication and gastropexy (Nissen repair). Ann Surg 104:927, 1966 5. Kent HG, Gompels BM: Treatment of reflux strictures of the esophagus by the Nissen- Rossetti operation. Thorax 2657, 1971 6. Nicholson DA, Nohl-Oser HC: Hiatus hernia: a comparison between two methods of fundoplication by evaluation of the long-term results. J Thorac Cardiovasc Surg 72:938, 1976 7. Woodward ER, Thomas HF, McAlhany JC: Comparison of crural repair and Nissen fundoplication in the treatment of esophageal hiatus hernia with peptic esophagitis. Ann Surg 173:782, 1971 8. Bremner CG: Gastric ulcer after the Nissen fundoplication. S Afr Med J 1:791, 1977 9. Bushkin FL, Woodward ER, OLeary JP: Occurrence of gastric ulcer after Nissen fundoplication. Am Surg 42:821, 1976 10. Scobie BA: High gastric ulcer after Nissen fundoplication. Med J Aust 1:409, 1979 11. Balison JR, Macgregor AMC, Woodward ER: Postoperative diaphragmatic herniation following transthoracic fundoplication. Arch Surg 106:164, 1973 12. Cordiano C, Querci DR, Aguniaro -- S, Mazzilli G: Technical modification of the Nissen fundopli- cation and Barrett s esophagus. Surgery 82:521, cation procedure. Surg Gynecol Obstet 143:977, 1977 1976 2. DeMeester TR, Johnson LF, Kent AH: Evaluation 13. Ikard RE, Jacobs JK: Gastropericardial fistula and of current operations for the prevention of pericardial abscess: unusual complications of gastroesophageal reflux. Ann Surg 180:511, subphrenic abscess following Nissen fundopli- 1974 cation. South Med J 67:17, 1974