Fundoplication Complications



Fundoplication Complications


Michael P. Federle, MD, FACR





Key Facts


Terminology



  • Nissen FDP: Complete (360°) FDP


  • Toupet FDP: Partial (270°) FDP, posterior side


  • Belsey Mark IV repair: 240° FDP wrap around left lateral aspect


Imaging



  • “Wrap” complications



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


    • Complete disruption of FDP sutures (recurrent hernia and reflux)


    • Partial disruption of FDP sutures (1 or more loose-looking outpouchings of wrap)


    • Complete wrap may slide downward over stomach; “hourglass” configuration of stomach


    • Intrathoracic migration of wrap upward through hiatus


  • Fluid collections in abdomen or mediastinum



    • Herniated abdominal fluid, lymph, hematoma, infection ± leak, abscess


  • Videofluoroscopic contrast-enhanced esophagram soon after surgery



    • Structural information, anatomical abnormalities


    • “Wrap” complications, leaks, persistence of reflux


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


Top Differential Diagnoses



  • Postoperative edema


  • Plication defect


  • Extragastric complications


Diagnostic Checklist



  • Postoperative fluoroscopic evaluation should be used liberally or even routinely


  • CT for suspected leak or bleeding






(Left) Graphic shows a Nissen fundoplication with the gastric fundus wrapped around the gastroesophageal junction. (Right) Upper GI series shows an intact but “tight” fundoplication with persistent dilation of the esophagus and delayed emptying. The undersurface of the wrap is seen as a filling defect image within the gastric fundus.






(Left) Axial NECT shows an intact fundoplication 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. (Right) Axial CECT shows a large collection of gas and fluid image in the mediastinum (sterile) following surgery. This is not rare, especially following laparoscopic repair of a large paraesophageal hernia.



TERMINOLOGY


Abbreviations



  • Fundoplication (FDP)


Definitions



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


  • Nissen FDP: Complete (360°) FDP



    • Approach: Laparoscopic or open FDP


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


    • Concomitant diaphragmatic hernia reduced; diaphragmatic esophageal hiatus sutured


  • Toupet FDP: Partial (270°) FDP



    • Posterior hemivalve created


  • Belsey Mark IV repair: Open surgical; 240° FDP wrap around left lateral aspect of distal esophagus



    • Fundus sutured to intraabdominal esophagus; acute esophagogastric junction angle (angle of His)


    • Can also be performed via minimally invasive techniques


IMAGING


General Features



  • “Wrap” complications



    • Slipped or misplaced FDP


    • FDP disruption or breakdown


    • FDP herniation with intrathoracic migration


    • Too tight, too loose, or too long FDP


    • Herniation of stomach through diaphragmatic hiatus


  • “Nonwrap” complications



    • Injury to intraabdominal, intrathoracic organs


    • Leaks: Intraabdominal, intrathoracic


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


    • Fistulas; gastropericardial, gastrobronchial, etc.


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


  • Late complications



    • Recurrent paraesophageal herniation


    • Distal esophageal stricture


Radiographic Findings

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Jun 8, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Fundoplication Complications

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