Fundoplication Complications

 GE junction (at B ring) will be above diaphragm; intact wrap around proximal stomach (neoesophagus) will be below diaphragm


• Preoperative: Identify “short esophagus,” hiatal hernia, and dysmotility

• Wrap complications
image Tight FDP wrap (fixed narrowing and delayed emptying of esophagus)

image Complete disruption of FDP sutures (recurrent hernia and reflux), partial disruption of FDP sutures (1 or more loose-looking outpouchings of wrap)


image Intact wrap may slide downward over stomach; “hourglass” configuration of stomach

image Intrathoracic migration of wrap upward through hiatus

• Fluid collections in abdomen or mediastinum
image Herniated abdominal fluid, lymph, hematoma, infection ± leak, abscess

• Videofluoroscopic contrast-enhanced esophagram soon after surgery is mandatory
image Provides structural information, anatomical abnormalities

image Wrap complications, leaks, persistence of reflux

• CT for severe abdominal or chest pain, suspected visceral injury, or abscess


• Postoperative fluoroscopic evaluation should be used liberally or even routinely

• CT for suspected leak or bleeding

(Left) Graphic shows a Nissen fundoplication (FDP) with the gastric fundus wrapped completely (360°) around the gastroesophageal junction.

(Right) Upright spot film from an esophagram performed soon after a Nissen FDP shows an intact wrap image in its expected subdiaphragmatic location as a filling defect within the air-filled fundus. The distal 3 cm of the esophageal lumen is compressed as it passes through the wrap.

(Left) A supine film from the same study shows the intact wrap image as a filling defect with the barium pool in the fundus.

(Right) Axial NECT shows an intact FDP as a soft tissue density mass image within the gastric fundus. The metallic staple line is evident within the wrap. The mass effect of the wrap tends to decrease with time following surgery.



• Fundoplication (FDP)


• Complications of antireflux surgery for management of gastroesophageal reflux disease (GERD)

• Nissen FDP: Complete (360°) FDP
image Approach: Laparoscopic or open FDP

image Gastric fundus wrapped 360° around intraabdominal esophagus to create antireflux valve

image Concomitant hiatial hernia is reduced; diaphragmatic esophageal hiatus sutured

• Toupet FDP: Partial (270°) FDP
image Posterior hemivalve created

• Belsey Mark IV repair: Open surgical; 240° FDP wrap around left lateral aspect of distal esophagus
image Fundus sutured to intraabdominal esophagus; acute esophagogastric junction angle (angle of His)

image Can also be performed via minimally invasive techniques


General Features

• “Wrap” complications
image Slipped or misplaced FDP

image FDP disruption or breakdown

image FDP herniation with intrathoracic migration

image Too tight, too loose, or too long FDP

image Herniation of stomach through diaphragmatic hiatus

• “Non-wrap” complications
image Injury to intraabdominal, intrathoracic organs

image Leaks: Intraabdominal, intrathoracic

image Mediastinal collection of gas and fluid (blood, transudate, or pus)

image Fistulas; gastropericardial, gastrobronchial, etc.

image Pneumothorax, pneumonia, pancreatitis, incisional hernia, mesenteric and portal venous thrombosis

• Late complications
image Recurrent paraesophageal herniation

image Distal esophageal stricture

Radiographic Findings

• Fluoroscopy

• Preoperative evaluation is critical to identify
image Presence, type and size of hiatal hernia (HH)

image Irreducible HH or “short esophagus”
– Stomach is pulled taut into chest; does not return to abdomen on upright positioning

– May require Collis gastroplasty (effectively lengthening esophagus by creating a gastric tube)

– Wrap goes around “neoesophagus” in abdomen = Nissen-Collis FDP

image Also evaluate for reflux and esophageal motility
– FDP is relatively contraindicated in patients with severe dysmotility

• Normal postoperative appearance
image Nissen FDP wrap: Well-defined mass in gastric fundus; smooth contour and surface
– Distal esophagus tapers smoothly through center of symmetric compression by wrap

– Tapered segment 2-3 cm long

– Pseudotumoral defect within gastric fundus = wrap
image Defect more pronounced for complete wrap of Nissen than partial wrap of Toupet, Belsey

image Best detected on upright film (wrap outlined by air in fundus), or supine (wrap as filling defect in barium pool)

image Toupet (partial, posterior) FDP
– Barium may fill portions of wrap
image Don’t mistake for leak or dehiscence

image Distal esophagus should still be “squeezed”

image Nissen-Collis procedure
– Gastroesophageal (GE) junction (at B ring) will be above diaphragm

– Intact wrap around proximal stomach (neoesophagus) will be below diaphragm
image Look for gastric folds within neoesophagus

image Belsey Mark IV repair
– Wrap produces smaller defect than Nissen FDP

– 2 distinct angles form as esophagus passes FDP

– Shallow upper angle; where esophagus, fundus, and diaphragm suture together

– Steep lower angle; where stomach pulled upward

• “Wrap” complications
image Tight FDP wrap
– Fixed narrowing of distal esophagus with delayed emptying

– May also see gas distention of stomach (gas bloat syndrome)

– May also be caused by excessive closure of esophageal hiatus of diaphragm

image Complete disruption (dehiscence) of FDP sutures
– Findings may resemble those of normal patient who has had no surgery

– Recurrent hiatal hernia and gastroesophageal reflux

– Gastric outpouching above diaphragm

– Expected mass of FDP wrap and narrowing of distal esophagus are not seen

Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Fundoplication Complications

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