GERD: Side Effects and Complications of Fundoplication
GERD: Side Effects and Complications of Fundoplication
Poor functional outcome after antireflux surgery usually can be traced to inadequate patient selection or technical problems encountered during the operation. In other cases, a different set of complications become manifest clearly during the operation or immediately postoperatively and potentially can lead to significant morbidity if not immediately recognized and treated.
Bowel perforation, especially of the esophagus and stomach, can be life-threatening and lead to longer hospital stay. The perforation rate reported in the literature varies according to technique and exposure, ranging from 0%–4%, with the highest incidences being reported with redo fundoplications. Injury may occur during placement of the camera port with a trocar, from excessive retraction on the stomach, passage of the esophageal bougie, or during lysis of adhesions. Because it is not possible to palpate a bougie or nasogastric tube during laparoscopy, correction of the esophagogastric angulation by appropriate traction on the stomach is critical to avoid damage during bougie passage. The importance of experience in passing the tube or dilator is also important; this should be done by an experienced anesthesiologist or surgeon. The frequency of perforation during laparoscopic operation is no higher than the conventional open approach of laparotomy. The greatest threat to the patient is unrecognized damage to the esophagus or stomach, which can be at least partly prevented by frequent leakage testing during the operation. If the perforation is recognized and repaired during the index operation, the patient's subsequent course is usually uneventful, and the functional results are excellent.
Usually the bleeding encountered during antireflux surgery is minor and easily controlled. Most commonly, bleeding occurs during division of the short gastric vessels, which is necessary to mobilize the fundus of the stomach. This technique generally includes dissecting and cutting the short gastric vessels arising from the spleen. Bleeding and tears of the splenic capsule were common after the open laparotomy and fundoplication, requiring splenectomy in 5%–11% of cases; however, the rate has decreased to <1% after laparoscopic procedures. This decrease in morbidity is due to better exposure of the abdominal organs induced by the pneumoperitoneum and improvements in laparoscopic techniques (ie, ultrasonic shears that coagulate blood vessels as they divide tissue), facilitating division of the short gastric vessels with less trauma to the spleen. Not unexpectedly, patients in whom accidental splenectomy has to be carried out have an increased rate of infection complications as well as a slight but definite increased postoperative mortality rate.
During mediastinal dissection, it is not uncommon to create a tear of one or both pleura. Rates of pneumothorax during laparoscopic antireflux surgery in most series range from 0%–1.5% but may be as high as 10% especially in repairing paraesophageal hernias.
This can be a major problem after laparoscopic antireflux surgery, causing both patient discomfort and harm to the newly created fundoplication. Up to 60% of patients have severe postoperative nausea, with as many as 5% experiencing vomiting in the recovery unit or hospital room after laparoscopic fundoplication. Routine prophylactic treatment with intravenous antiemetics such as ondansetron is recommended. Patients who retch or vomit in the early postoperative period are at risk of disrupting the crural closure and/or intrathoracic herniation of the fundoplication. Patients with early postoperative vomiting should undergo immediate barium esophagogram to access the integrity of the fundoplication. If a disruption is identified, the patient should be taken back to surgery as early as possible. If reoperation is performed within 4–10 days, the procedure is usually relatively simple, but if it is delayed until adhesions develop, the anatomy may be difficult to discern and manage.
Acute Perioperative and Immediate Postoperative Complications
Poor functional outcome after antireflux surgery usually can be traced to inadequate patient selection or technical problems encountered during the operation. In other cases, a different set of complications become manifest clearly during the operation or immediately postoperatively and potentially can lead to significant morbidity if not immediately recognized and treated.
Gastrointestinal Visceral Perforation
Bowel perforation, especially of the esophagus and stomach, can be life-threatening and lead to longer hospital stay. The perforation rate reported in the literature varies according to technique and exposure, ranging from 0%–4%, with the highest incidences being reported with redo fundoplications. Injury may occur during placement of the camera port with a trocar, from excessive retraction on the stomach, passage of the esophageal bougie, or during lysis of adhesions. Because it is not possible to palpate a bougie or nasogastric tube during laparoscopy, correction of the esophagogastric angulation by appropriate traction on the stomach is critical to avoid damage during bougie passage. The importance of experience in passing the tube or dilator is also important; this should be done by an experienced anesthesiologist or surgeon. The frequency of perforation during laparoscopic operation is no higher than the conventional open approach of laparotomy. The greatest threat to the patient is unrecognized damage to the esophagus or stomach, which can be at least partly prevented by frequent leakage testing during the operation. If the perforation is recognized and repaired during the index operation, the patient's subsequent course is usually uneventful, and the functional results are excellent.
Bleeding and Splenic Injury
Usually the bleeding encountered during antireflux surgery is minor and easily controlled. Most commonly, bleeding occurs during division of the short gastric vessels, which is necessary to mobilize the fundus of the stomach. This technique generally includes dissecting and cutting the short gastric vessels arising from the spleen. Bleeding and tears of the splenic capsule were common after the open laparotomy and fundoplication, requiring splenectomy in 5%–11% of cases; however, the rate has decreased to <1% after laparoscopic procedures. This decrease in morbidity is due to better exposure of the abdominal organs induced by the pneumoperitoneum and improvements in laparoscopic techniques (ie, ultrasonic shears that coagulate blood vessels as they divide tissue), facilitating division of the short gastric vessels with less trauma to the spleen. Not unexpectedly, patients in whom accidental splenectomy has to be carried out have an increased rate of infection complications as well as a slight but definite increased postoperative mortality rate.
Pneumothorax
During mediastinal dissection, it is not uncommon to create a tear of one or both pleura. Rates of pneumothorax during laparoscopic antireflux surgery in most series range from 0%–1.5% but may be as high as 10% especially in repairing paraesophageal hernias.
Postoperative Nausea and Vomiting
This can be a major problem after laparoscopic antireflux surgery, causing both patient discomfort and harm to the newly created fundoplication. Up to 60% of patients have severe postoperative nausea, with as many as 5% experiencing vomiting in the recovery unit or hospital room after laparoscopic fundoplication. Routine prophylactic treatment with intravenous antiemetics such as ondansetron is recommended. Patients who retch or vomit in the early postoperative period are at risk of disrupting the crural closure and/or intrathoracic herniation of the fundoplication. Patients with early postoperative vomiting should undergo immediate barium esophagogram to access the integrity of the fundoplication. If a disruption is identified, the patient should be taken back to surgery as early as possible. If reoperation is performed within 4–10 days, the procedure is usually relatively simple, but if it is delayed until adhesions develop, the anatomy may be difficult to discern and manage.
Source...