1 Failed Fundoplication: GI Perspective Philip Katz MD MACG, AGAF Professor of Medicine Director GI function Laboratories Weill Cornell Medicine Disclosure • Consultant Phathom Pharma 1 2
Failed Fundoplication: GI Perspective
Feb 03, 2023
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Microsoft PowerPoint - Katz_Failed Fundoplication - Compatibility ModeDirector GI function Laboratories Weill Cornell Medicine
Disclosure
• Failure comes in many forms
• Most are NOT true failure but residual symptoms or new functional symptoms
• Do your best to buy time as redo is not fun for you or the patient
• Work everyone up carefully
What circumstance • I sent the patient and symptoms have returned, did
not improve or new symptom. In this case I know the surgeon and their skills
• New consult for a patient operated on by surgeon I know
• New consult for a patient with surgeon I do not know
• A patient who has failed more than one operation
3
4
3
• Any post op testing prior to visit
• If multiple failed fundoplication not as helpful to know details
Nissen/Partial/Normal
5
6
4
Herniated Wrap
disruption of the crural repair or failure to perform the initial wrap over a tension-free segment of intra-abdominal esophagus.
7
8
5
Herniated/Slipped Wrap
• Bloating, abdominal distention, early satiety, nausea, upper abdominal pain, flatulence, inability to belch, and inability to vomit.
Gas Bloat • Inability of the GEJ to relax in response to gastric distention
• Aerophagia: becomes problematic after fundoplication when the air cannot be vented
• Impairment of meal-induced receptive relaxation and accommodation of the stomach with rapid gastric emptying
• Vagal injury which delays gastric emptying and interferes with transient relaxation that is part of the normal belch reflux.
15
16
9
Gas Bloat • I often do EGD, Barium with tablet and CT scan for
reassurance to the patient
• Helps me be certain of anatomy
• Will do gastric emptying, SIBO testing and GI transit studies if history of IBS, other functional disease or constipation (which I always treat)
• Patience is a key virtue here
Gas Bloat Management • dietary modifications to avoid gas-producing foods
and carbination
• cessation of smoking,
• gas-reducing agents (5)
• Biofeedback?
17
18
10
• Take down redo if patient runs out of patience
Dysphagia • Too tight for their functional esophageal pump,
• Previously unrecognized achalasia
• Healed peptic stricture
• Distal migration of the wrap onto the stomach
19
20
11
• Almost always solids only
• Persistent after 2-3 months needs evaluation with EGD, Timed barium with tablet, endoflip and HRM if needed
• Dilation at <3 months successful often, later quite variable
Diarrhea • Rapid gastric emptying from the fundoplication
overloading the small intestine's ability to handle the osmotic bolus (Dumping syndrome)
• Vagal injury with subsequent small bowel overgrowth
• Exacerbation of underlying irritable bowel syndrome.
21
22
12
Diarrhea
• Nutrition
Recurrent Heartburn/Regurgitation
• Always work up: EGD with 96 hour Bravo off PPI for 2-4 weeks
• If recurrent GERD will respond to optimized medical therapy
23
24
13
Disclosure
• Failure comes in many forms
• Most are NOT true failure but residual symptoms or new functional symptoms
• Do your best to buy time as redo is not fun for you or the patient
• Work everyone up carefully
What circumstance • I sent the patient and symptoms have returned, did
not improve or new symptom. In this case I know the surgeon and their skills
• New consult for a patient operated on by surgeon I know
• New consult for a patient with surgeon I do not know
• A patient who has failed more than one operation
3
4
3
• Any post op testing prior to visit
• If multiple failed fundoplication not as helpful to know details
Nissen/Partial/Normal
5
6
4
Herniated Wrap
disruption of the crural repair or failure to perform the initial wrap over a tension-free segment of intra-abdominal esophagus.
7
8
5
Herniated/Slipped Wrap
• Bloating, abdominal distention, early satiety, nausea, upper abdominal pain, flatulence, inability to belch, and inability to vomit.
Gas Bloat • Inability of the GEJ to relax in response to gastric distention
• Aerophagia: becomes problematic after fundoplication when the air cannot be vented
• Impairment of meal-induced receptive relaxation and accommodation of the stomach with rapid gastric emptying
• Vagal injury which delays gastric emptying and interferes with transient relaxation that is part of the normal belch reflux.
15
16
9
Gas Bloat • I often do EGD, Barium with tablet and CT scan for
reassurance to the patient
• Helps me be certain of anatomy
• Will do gastric emptying, SIBO testing and GI transit studies if history of IBS, other functional disease or constipation (which I always treat)
• Patience is a key virtue here
Gas Bloat Management • dietary modifications to avoid gas-producing foods
and carbination
• cessation of smoking,
• gas-reducing agents (5)
• Biofeedback?
17
18
10
• Take down redo if patient runs out of patience
Dysphagia • Too tight for their functional esophageal pump,
• Previously unrecognized achalasia
• Healed peptic stricture
• Distal migration of the wrap onto the stomach
19
20
11
• Almost always solids only
• Persistent after 2-3 months needs evaluation with EGD, Timed barium with tablet, endoflip and HRM if needed
• Dilation at <3 months successful often, later quite variable
Diarrhea • Rapid gastric emptying from the fundoplication
overloading the small intestine's ability to handle the osmotic bolus (Dumping syndrome)
• Vagal injury with subsequent small bowel overgrowth
• Exacerbation of underlying irritable bowel syndrome.
21
22
12
Diarrhea
• Nutrition
Recurrent Heartburn/Regurgitation
• Always work up: EGD with 96 hour Bravo off PPI for 2-4 weeks
• If recurrent GERD will respond to optimized medical therapy
23
24
13
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