Herniation of an abdominal antireflux fundoplication into the chest: what does it mean?

Abstract

OBJECTIVES:The specific contribution of the herniation of an abdominal antireflux fundoplication into the chest to symptomatic and therefore surgical failure remains unclear. METHODS:The study was conducted in 189 consecutive fundoplication patients, categorized as patients reoperated on for chest herniation of either an abdominal 360°(Group 1; n = 95) or a partial (Group 2; n = 10) fundoplication, and patients having undergone an intrathoracic 360°fundoplication for short oesophagus (Group 3; n = 84; reference group). There were four subgroups in Group 1: 1A: wrap still complete and perioesophageal; 1B: wrap still complete but perigastric; 1C: wrap still perioesophageal but partially disrupted and 1D: wrap perigastric and partially disrupted. RESULTS:The prevalence of defective symptoms (heartburn and regurgitation) was significantly lower (P < 0.0001) in Group 3 (0.0%) and Subgroup 1A (3.7%) than in Subgroups 1B (84.4%), 1C (86.7%) and 1D (100%) and Group 2 (100%). The prevalence of obstructive symptoms (dysphagia, chest pain, necrosis and perforation) was significantly higher (P < 0.0001) in Subgroup 1A (100%) than in Subgroups 1B (57.8%), 1C (60.0%) and 1D (25.0%). The prevalence of a short oesophagus, an abdominal wall hernia repair and high abdominal pressure episodes in reoperated patients were 13.7, 36.2 and 67.2%, respectively. CONCLUSIONS:Unlike perigastric or partial fundoplication, a 360°perioesophageal abdominal fundoplication, when herniated into the chest, is still effective against reflux. Obstructive symptoms are due to either diaphragmatic strangulation or perigastric migration of the wrap (slipknot effect). Short oesophagus, weakness of the abdominal wall and high abdominal pressure episodes favour the herniation process.

Clinical Outcomes of Reoperation for Failed Antireflux Operations

“…Lastly, axial tension also needs to be recognized in the form of a shortened esophagus and should be addressed in the primary and revision operation using the techniques of Collis gastroplasty or the Nissen-Hill hybrid approach, as was used in some patients in this series [26,27]. This notion has also been expanded in a recent study analyzing fundoplication herniations into the chest, which identified that patients with a short esophagus may not be good candidates for ARS because a slipped or perigastric wrap was found not to function properly in the chest [28]. One of the key issues raised in performing revision ARS is the higher complication rate and associated morbidity.…”