Classic Nissen fundoplication surgery. Laparoscopic nissen fundoplication Which nissen or blunt operation should be done
Nissen fundoplication can be performed via abdominal or thoracic access. However, the thoracic approach leads to many severe postoperative complications, such as esophageal-pleural or gastropleural fistulas, ulcers in the fundoplication area, etc. Because of these and other complications, the thoracic approach is rarely used. Therefore, we will describe only the abdominal approach.
Transabdominal Nissen surgery consists of forming a 360" cuff around the lower esophagus using the fundus of the stomach. The original Nissen technique, although it leads to reliable cessation of gastroesophageal reflux, can also lead to serious postoperative complications. In order to reduce the number of these complications, while maintaining This is the value of the Nissen technique as an anti-reflux operation, it has been modified. Complications encountered with the classical Nissen technique are the following: dysphagia, difficulty regurgitating and vomiting, gas bloating syndrome, sliding of the fundoplication down into the body of the stomach, causing its obstruction, sliding of the fundoplication into the chest cell, fundoplication dehiscence, gastric cuff ulceration, etc.
Operation Nissen consists of simply wrapping the stomach around the lower esophagus. It is absolutely necessary to have sufficient experience in successfully performing this operation and reliable patient selection criteria. It is important to assess the degree of pressure that the fundus of the stomach must exert on the esophagus, determine the required height of the cuff and accurately select the segment of the stomach from which it is formed. Many complications of this operation are due to the use of inadequate techniques and poor patient selection. Patients with esophageal motility disorders, uncoordinated motility, weak waves, or lack of peristalsis should not undergo the Nissen procedure, especially those who have symptoms of dysphagia for these reasons. Patients with severe esophagitis, stricture or shortening of the esophagus, in whom the esophagus cannot be brought down sufficiently into the abdominal cavity, or in whom there is residual tension on the esophagus, should not undergo this operation. To properly select patients undergoing this operation, a complete preoperative evaluation, including manometry and 24-hour pH monitoring, is absolutely necessary.
Operation Nissen- a technique that is most often used to treat hiatal hernias with reflux. The proposed technical modifications, developing the original method, significantly reduced the incidence of complications. We will continue to describe the Nissen operation with modifications proposed in recent years. Release of the lower esophagus and fundus is performed in the same way as in the Hill operation.
The figure shows that the lower esophagus and esophagogastric junction. The gastrophrenic ligament is divided, and the three short vessels are divided and ligated proximally. A nasogastric tube (18F) was inserted into the patient. The esophageal opening of the diaphragm is sutured behind the esophagus with five sutures of non-absorbable threads. Some surgeons believe that there is no need to ligate short vessels when performing a Nissen fundoplication. However, most surgeons believe that in order to adequately mobilize the fundus of the stomach, select the appropriate segment and perform 360° inversion without tension, it is absolutely necessary to ligate at least three short vessels.
Before proceeding with fundoplication, it is necessary to ensure that esophageal opening of the diaphragm sutured correctly. This means that between the esophagus, into which the nasogastric tube is inserted, and the edge of the esophageal opening, it is permissible to insert only the tip of the right index finger, as shown in the figure. If the tip of the index finger cannot be passed through the esophageal opening of the diaphragm, this means that it is too narrowed, and the position of the suture closest to the esophagus must be changed. If the remaining space is too large, add one or two stitches so that only the tip of your index finger fits into the hole. Too wide a space between the esophagus and the edge of the esophageal hiatus makes it easier for the fundoplication to move into the chest.
In the illustration shows the moment when the fundus fold is wrapped around the lower esophagus. The surgeon performs screwing with the index and middle fingers of the right hand. Once the fundus is advanced to the right edge of the esophagus, it is grasped with a Babcock forceps to complete the maneuver. If the three short vessels at the top of the stomach are previously divided, then this maneuver can be performed correctly and without tension. The figure shows that a sufficient portion of the esophagus has been brought down into the abdominal cavity to form a cuff without tension. The abdominal section of the esophagus should be 4-7 cm long. To form the cuff, only the fundic section of the stomach should be used. The proximal part of the body of the stomach should not be included in the cuff.
There are important functional differences between muscle fibers fundus and body of the stomach. The muscle fibers of the fundus contract and relax synchronously with the lower esophageal sphincter. During swallowing, if the fundic section is screwed onto the esophagus, at the moment of relaxation of the lower esophageal sphincter, the fundic section relaxes synchronously and the bolus of food passes into the stomach without difficulty. If the proximal part of the body of the stomach was used in the formation of the cuff, this segment will not relax, preventing the advancement of the bolus, and dysphagia will be observed in the postoperative period. DeMeester et al. demonstrated that using part of the body of the stomach to form a cuff around the esophagus is easy to make a mistake, since some patients have one, two, or even shorter vessels passing retroperitoneally.
Before applying sutures connecting both sides of the fundus around the esophagus, the anesthesiologist should retract the nasogastric tube into the mid-esophagus and insert a soft bougie such as Hurt or Maloney, 50 F. This dilating soft bougie should be performed after wrapping the fold around the esophagus. If the bougie is performed before the sutures are tied, the cuff shaping procedure may become more complicated. The purpose of using a bougie is to keep the cuff from excessive compression of the esophagus, leading to dysphagia, gas bloating syndrome, difficulty regurgitating and vomiting. It has been shown that to achieve cardia sufficiency there is no need to have a dense fundoplication. In addition, it should be noted that during the Nissen operation there is another factor leading to compression of the abdominal esophagus. This is air in the stomach that compresses the esophagus through the fundus fold.
The figure shows a Hurst 50 F bougie inserted into the stomach. Two 2-0 prolene sutures were applied, including serous, muscular and submucosal layers of the fundus folds on the left, further passing through the wall of the esophagus and including both muscle layers, then the serous layer of the fundal fold on the right. It is important that the sutures include the submucosal layer, since this is the most powerful layer of the gastrointestinal tract. To avoid serious postoperative complications, care should be taken not to perforate the gastric and esophageal mucosa. Some surgeons use small gauge bougies, 36 or 40 F, others use large bougies up to 60 F. Not all authors pass sutures through the muscular wall of the esophagus, as they believe that this is not of great importance due to the low density of the muscle layer. Other authors, however, believe that these sutures on the esophagus contribute to the fusion of the fundal cuff with it.
Two prolene seams 2-0 on the fundus cuff are tied with a Hurt 50 F bougie. It should be possible to insert a finger between the esophagus and the cuff without difficulty. If it is impossible to insert a finger or it is difficult to insert, a fundoplication correction is necessary. If a large gap is detected with the finger between the fundic fold and the esophagus, then the necessary correction must also be made.
Height anterior segment fundoplication should be 1.5-2 cm. This is the height that is achieved using two seams. High altitude can lead to symptoms of obstruction. DeMeester creates a cuff as low as 1 cm high by placing a single mattress suture on a Teflon pad.
After the formation of fundoplasty the soft bougie is removed, and the previously partially removed nasogastric tube is returned to its place. Repeatedly, as shown in the figure, the index finger is inserted between the esophagus and the cuff. Without a bougie, it is easier to gradually insert the index finger inside, and even two fingers can pass through the gap. If the described technique is followed exactly, postoperative symptoms of obstruction rarely develop. In some patients, however, even with all precautions taken in the postoperative period, swallowing may be difficult for 2-4 weeks due to local tissue swelling.
Some patients with difficulty swallowing may be longer. For this reason, it is advisable to leave the nasogastric tube in place for at least 1 week. Some surgeons, in order to avoid the discomfort of having a nasogastric tube in the lumen of the esophagus for a week, prefer to achieve gastric decompression through gastrostomy (6). Gastrostomy, in addition to very effective decompression, helps fix the stomach to the anterior abdominal wall, preventing its displacement into the chest. Given this, some surgeons recommend fixing the gastric cuff to the right crura of the diaphragm (16). Others recommend fixing it to the medial arcuate ligament with several sutures. To improve fixation of the fundic fold, Rossetti suggested placing two or three sutures involving the cuff and the anterior gastric wall, as shown in the inset.
Schematic section of the lower esophagus and proximal upper stomach in patients undergoing Nissen fundoplication. This figure graphically illustrates that in addition to the pressure exerted on the esophagus by the gastric cuff, there is another compression factor that is usually not taken into account when performing a Nissen fundoplication. This factor is air, which, rising to the area of the gastric fold, increases pressure on the wall of the lower esophagus through the cuff. To prevent symptoms of esophageal obstruction when performing a Nissen fundoplication, the pressure that this air will exert on the lower esophagus must be taken into account.
Operation Belsey produced by thoracic access. This makes it possible to mobilize the esophagus from the diaphragm to the aortic arch, often making it possible to bring down a segment of the lower esophagus and the gastro-gastric junction into the abdominal cavity, which is not always possible with abdominal access. In addition, the Belsey procedure includes a 240 fundoplication, which effectively helps create an anti-reflux barrier.
Today, Nissen fundoplication is performed both openly and using laparoscopic techniques. This is one of the most common operations now performed for hiatal hernia.
The essence of this surgical intervention is to create a cuff by rotating the fundus of the stomach around the esophagus by 360°, which prevents gastroesophageal reflux, and, consequently, the development of esophagitis. The operation is usually performed from the abdominal approach, performing an upper median laparotomy.
After the proximal part of the stomach is brought down from the thoracic cavity to the abdominal cavity, the abdominal esophagus is isolated along its entire length. Then the latter is carefully taken onto a special holder, the hepatogastric ligament is cut and the posterior surface of the upper third of the stomach is mobilized.
The next step is to stitch the legs of the diaphragm, thereby reducing the diameter of the esophageal opening. After that, separate seromuscular sutures connect the anterior and posterior walls of the upper part of the stomach to each other, as if forming a coupling running around the abdominal esophagus. At the same time, in order to avoid slipping of the formed cuff in the distal direction (the development of the so-called telescope syndrome), these sutures also capture the muscular layer of the anterior wall of the esophagus, which prevents relapse of the disease. At the end of this intervention, the anterior wall of the stomach is fixed to the anterior abdominal wall with separate sutures, passing the thread through the posterior plate of the sheath of the left rectus abdominis muscle.
It should be noted that with the long-term existence of a sliding hiatal hernia and the resulting peptic esophagitis in approximately 5-10% of cases, secondary shortening of the esophagus occurs, causing significant difficulties during the operation, namely, when moving the proximal part of the stomach down into abdominal cavity.
In such situations, the Nissen intervention is performed not from the laparotomy, but from the left transthoracic approach, leaving part of the stomach in the pleural cavity.
However, this approach is associated with a number of complications, ranging from the loss of the natural regurgitation reflex due to the fact that the cuff here is an absolute valve in the cardia region, since it is created not around the esophagus, which in such a situation is completely located in the chest, but around the stomach, to serious troubles such as the formation of esophageal-pleural or gastropleural fistulas and ulcers in the fundoplication area, etc.
In general, for successful Nissen fundoplication, it is necessary to comply with certain patient selection criteria and, in terms of preoperative preparation, carry out 24-hour pH-metry and manometry.
It is imperative to assess in advance the degree of pressure that the fundus of the stomach should exert on the esophagus, set the optimal height of the cuff and accurately outline the segment of the stomach from which it will be formed.
Under no circumstances should persons suffering from motility disorders, esophageal dyskinesia, weak waves or complete absence of peristalsis be subjected to this intervention. Nissen surgery is also not recommended for patients with severe esophagitis, shortening and stricture of the esophagus, when the esophagus cannot be lowered to a sufficient length into the abdominal cavity or when there is residual tension of the esophagus.
A) Indications for fundoplication according to Nissen-Rosetti and Toupet:
- Planned: persistent reflux disease, despite conservative treatment for incompetence of the lower esophageal sphincter; the operation is usually performed laparoscopically.
- Contraindications: symptoms of reflux due to problems with gastric emptying or poor esophageal motility.
- Alternative operations: Belsey-Mark IV fundoplication, laparoscopic surgery.
b) Preoperative preparation:
- Preoperative studies: endoscopy, x-ray examination of the upper gastrointestinal tract, manometry, 24-hour pH-metry, exclusion of cholelithiasis and gastric ulcer.
- Patient preparation: preoperative dilatation of strictures.
V) Specific risks, informed consent of the patient:
- Temporary dysphagia (5-10% of cases)
- Nausea/belching
- Damage to the esophagus, stomach, spleen (5% of cases) and vagus nerve
- Weakening/displacement of the cuff
- Relapse (less than 5% of cases)
G) Anesthesia. General anesthesia (intubation).
d) Patient position. Lying on your back.
e) Nissen-Rosetti and Toupet fundoplication approach. For a conventional operation, as a rule, an abdominal approach (superior laparotomy) is used.
and) Stages of fundoplication according to Nissen-Rosetti and Toupet:
- Access
- Displacement of the fundus of the stomach
- Sewing the cuff from the bottom
h) Anatomical features, serious risks, surgical techniques:
- The left lobe of the liver, together with the left triangular ligament, lies anterior to the esophagogastric junction.
- The trunks of the vagus nerves lie on the anterior and posterior surfaces of the esophagus.
- The fundus of the stomach lies above the cardia and is close to the spleen.
- Warning: Be especially careful in the area of the short gastric veins.
- Warning: Be aware of the accessory left hepatic artery, which sometimes arises from the left gastric artery.
- Once anesthesia has begun, insert a thick (40 Fr) nasogastric tube, which is replaced at the end of the operation with a regular nasogastric tube.
- A short cuff (2-3 cm) is sufficient.
- Make sure the cuff is loose and free of tension.
And) Measures for specific complications. If damage to the esophagus occurs, immediately suture it and cover it with a cuff from the fundus of the stomach.
To) Postoperative care after Nissen-Rosetti and Toupet fundoplication:
-Medical care: Remove active drainage and nasogastric tube after 1-2 days.
- Resumption of nutrition: from 1-2 days.
- Activation: immediately.
- Period of incapacity: 1-2 weeks.
l) Surgical technique of fundoplication according to Nissen-Rosetti and Toupet:
- Access
- Mobilization of the left lobe of the liver
- Exposure of the distal esophagus
- Skeletonization of the proximal part of the greater curvature
- Bottom displacement
- Sewing the cuff from the bottom
- Confirmation of cuff width
1. Access. A median laparotomy is performed to the left of the navel with the patient lying on his back with the upper body hyperextended. Currently, the best approach is laparoscopic surgery.
2. Mobilization of the left lobe of the liver. After opening the abdominal cavity, retractors are inserted and the left lobe of the liver is mobilized. It is recommended to cross the triangular ligament in its lateral part between Overholt clamps and ligate its stumps with suturing, taking into account that bleeding may occur here. The left triangular ligament is then divided with scissors or diathermy near the hepatic vein.
The left lobe of the liver is shifted to the left and laterally, covered with moist swabs and held in this position throughout the operation. This provides good visualization of the esophageal opening of the diaphragm.
3. Exposure of the distal esophagus. A tampon placed behind the spleen reduces the tension of the ligamentous apparatus between the stomach and spleen. The peritoneum is transversely incised over the distal esophagus. The dissection is carefully advanced to the left or right of the esophagus, carefully preserving the vagus nerve trunks, until the esophagus is approximately 3 cm exposed and can be completely bypassed. You can also draw a loop around the esophagus.
4. Skeletonization of the proximal part of the greater curvature. A sequential dissection of the greater curvature is performed over 3 cm by intersecting the short gastric vessels. During this stage, the spleen is carefully protected. The vessels must be ligated and divided separately.
5. Displacement of the fundus of the stomach. After sufficient mobilization, the dorsal 2-3 cm of a narrow cuff from the fundus of the stomach can be wrapped around the esophagus. The cuff from the bottom is grasped with a Duval clamp on the right and brought out ventrally. This maneuver can be facilitated by applying caudal traction on the band around the esophagus. A 40 Fr nasogastric tube inserted by the anesthesiologist. prevents the cuff from becoming too tight. Intraoperative gastroscopy also pursues the same goal.
6. Sewing the cuff from the bottom. The fundus cuff is loosely closed with two or three sutures proximal to the lower esophagus. The wall of the esophagus is included in the first and last suture. The cuff from the bottom should cover the esophagus without tension. Caudally it lies on the mesogastric part of the lesser curvature (i.e., on the hepatic branches), which for this reason must be isolated very sparingly. Suture material - silk 0.
7. Cuff width confirmation. Ultimately, the cuff should be wide enough to allow the surgeon's index finger and thumb to rest freely between the cuff and the esophagus (a). The part of the cuff from the bottom adjacent to the greater curvature can be fixed with two more sutures in the form of a hemifundoplication (b). At the end of the operation, the thick nasogastric tube is removed by the anesthesiologist and replaced with a standard nasogastric tube.
To date Nissen fundoplication(Nissen) is performed both openly and using laparoscopic techniques. This is one of the most common operations now performed for hiatal hernia.
The essence of this surgical intervention is to create a cuff by turning the fundus of the stomach around the esophagus by 360 degrees, which prevents gastroesophageal reflux, and, consequently, the development of esophagitis. The operation, as a rule, is carried out from the abdominal access, performing the upper median laparotomy.
After the proximal part of the stomach is brought down from the thoracic cavity to the abdominal cavity, the abdominal esophagus is isolated along its entire length. Then the latter is carefully taken onto a special holder, the hepatogastric ligament is cut and the posterior surface of the upper third of the stomach is mobilized.
The next step is to stitch the legs of the diaphragm, thereby reducing the diameter of the esophageal opening. After that, separate seromuscular sutures connect the anterior and posterior walls of the upper part of the stomach to each other, as if forming a coupling running around the abdominal esophagus. At the same time, in order to avoid slipping of the formed cuff in the distal direction (the development of the so-called telescope syndrome), these sutures also capture the muscular layer of the anterior wall of the esophagus, which prevents relapse of the disease. At the end of this intervention, the anterior wall of the stomach is fixed to the anterior abdominal wall with separate sutures, passing the thread through the posterior plate of the sheath of the left rectus abdominis muscle.
It should be noted that with the long-term existence of a sliding hiatal hernia and the resulting peptic esophagitis in approximately 5-10% of cases, secondary shortening of the esophagus occurs, causing significant difficulties during the operation, namely, when moving the proximal part of the stomach down into abdominal cavity.
In such situations, the Nissen intervention is performed not from the laparotomy, but from the left transthoracic approach, leaving part of the stomach in the pleural cavity.
However, this approach is associated with a number of complications, ranging from the loss of the natural regurgitation reflex due to the fact that the cuff here is an absolute valve in the cardia region, since it is created not around the esophagus, which in such a situation is completely located in the chest, but around the stomach, to serious troubles such as the formation of esophageal-pleural or gastropleural fistulas and ulcers in the fundoplication area, etc.
In general, for successful Nissen fundoplication, it is necessary to comply with certain patient selection criteria and, in terms of preoperative preparation, carry out 24-hour pH-metry and manometry.
It is imperative to assess in advance the degree of pressure that the fundus of the stomach should exert on the esophagus, set the optimal height of the cuff and accurately outline the segment of the stomach from which it will be formed.
Under no circumstances should persons suffering from motility disorders, esophageal dyskinesia, weak waves or complete absence of peristalsis be subjected to this intervention. Nissen surgery is also not recommended for patients with severe esophagitis, shortening and stricture of the esophagus, when the esophagus cannot be lowered to a sufficient length into the abdominal cavity or when there is residual tension of the esophagus.
Nissen fundoplication(English) Nissen fundoplication) is an anti-reflux operation, which consists in wrapping the bottom of the stomach around the esophagus, creating a cuff that prevents gastric contents from being thrown into the esophagus. For the first time, an antireflux operation - fundoplication was carried out by Rudolf Nissen in 1955, who proposed to form a sleeve from the upper part of the fundus of the stomach, which consisted of a 360-degree plication of a 5-cm cuff around the lower part of the esophagus (Vasnev O.S.). When carrying out fundoplication, not only the anatomical structure is restored, but also the functional state of the lower esophageal sphincter: the tone is restored, the number of transient relaxations during stretching of the stomach decreases, and its emptying improves.
Fig.1. General scheme of fundoplication according to Nissen
Nissen fundoplication can be performed either laparoscopically or openly. Nissen fundoplication, including its modifications, is currently considered the “gold standard” of antireflux surgery.
Nissen fundoplication is the most common surgical procedure for treating GERD. It can be performed laparoscopically by an experienced surgeon. The purpose of the operation is to increase pressure in the lower esophageal sphincter to prevent reflux. When performed by an experienced surgeon (who has performed at least 30–50 laparoscopic procedures), its success approaches that of well-planned and carefully executed therapeutic treatment with proton pump inhibitors. Side effects or complications associated with surgery occur in 5-20% of cases. The most common is dysphagia, or difficulty swallowing. It is usually temporary and resolves in 3-6 months. Another problem that occurs in some patients is their inability to burp or vomit. This is because the operation creates a physical barrier to any type of backflow of any stomach contents. The consequence of the inability to belch effectively is “gas-bloat” syndrome - bloating and discomfort in the abdomen (J. Richter et al. Gastroesophageal reflux disease (GERD) in questions and answers).
When choosing a long-term treatment strategy for patients who have achieved an effect from the use of proton pump inhibitors, surgical treatment is not advisable. No surgical operation can be performed with “zero” mortality. There is always a certain risk of complications. One of the important steps when performing antireflux surgery is the restoration of normal anatomical relationships in the area of the transition of the esophagus to the stomach. In this case, the lower esophageal sphincter should be below the diaphragm under the influence of high intra-abdominal pressure. Reconstruction of the legs of the diaphragm and valvuloplasty are carried out. If the operation is performed correctly, recurrence of a hiatal hernia is prevented for a long time, at least 10 years. Before the operation, mandatory diagnostic measures carried out before the operation include endoscopy, 24-hour pH monitoring, esophageal manometry, preferably an x-ray examination (Lundell L.).
The main tenet of the approach to antireflux surgery today is careful preoperative diagnosis. Before performing antireflux operations, it is necessary to confirm that the patient's symptoms are caused by the effect of pathological acid or alkaline reflux on the esophageal mucosa and that there is no neuromuscular disease of the esophagus and cardia. The study of the function of the esophagus includes esophagogastroduodenoscopy, x-ray examination of the upper gastrointestinal tract, (ideally), manometry of the esophagus (Vasnev O.S.).
Disadvantages of the Nissen fundoplication
Nissen fundoplication is the most commonly performed antireflux operation, but persistent control of gastroesophageal reflux does not occur in 30-76% of cases. Up to 30% of patients after antireflux surgery require reoperation due to the development of persistent dysphagia. Its causes may be inhibition of relaxation of the lower esophageal sphincter by a tightened cuff, impaired migration of the cardiac part of the stomach during swallowing, or impaired motility of the esophagus due to denervation of the abdominal esophagus, as well as a “slipped” anti-reflux cuff (Chernousov A.F. et al.).
Rice. 3. X-ray. Complications after Nissen fundoplication. a - dysphagia caused by an excessively tightly formed cuff; b - dysphagia caused by an excessively long fundoplication cuff. In both cases, signs of obstruction in the area of the esophagogastric junction and suprastenotic expansion of the esophagus above the applied cuff are visible (Chernousov A.F. et al.)
Another important and quite common complication of Nissen fundoplication surgery is the slippage of the cardia and fundus of the stomach with the terminal esophagus relative to the cuff (Fig. 4, b). As a rule, the reason for this is the cutting of the sutures between the cuff and the esophagus. Suturing the legs of the diaphragm when shortening the esophagus and fixing an anti-reflux cuff to them also leads to “slipping”, since the esophagus, having contracted after the operation, will pull the cardia along with the straightened cuff into the posterior mediastinum. Radiologically, this appears as an “hourglass” phenomenon, when one part of the cuff is above the diaphragm and the other below (Fig. 5). The complication is accompanied by severe dysphagia, regurgitation and heartburn, which, of course, requires repeated corrective surgery. A common mistake when using endoscopic techniques is the use of the body or even the antrum of the stomach when forming an antireflux cuff (see Fig. 4, c). If the short gastric vessels are not divided, the surgeon is forced to use not the bottom of the stomach, but its anterior wall during 360° fundoplication. All this leads to torsion, severe deformation of the stomach, which, for obvious reasons, is not able to perform an antireflux function and is the main reason for the high incidence of postoperative complications in the form of dysphagia (11-54%) with this method of surgery.
Rice. 4. Complications after Nissen fundoplication: a - complete reversal of the cuff when cutting the sutures; b - sliding of the cardia and fundus of the stomach with the terminal part of the esophagus relative to the cuff; c - a cuff formed around the cardiac part of the stomach; d - retraction of the antireflux cuff into the posterior mediastinum during shortening of the esophagus (Chernousov A.F. et al.)
Rice. 5. X-ray. “Slipped” fundoplication cuff: a - the slipped cuff is located below the level of the diaphragm and compresses the cardiac part of the stomach, the esophagogastric junction is located above the diaphragm; b, c - with double contrast, the folds of the gastric mucosa inside the slipped cuff with the formation of a diverticulum-like deformity are clearly visible (such a diverticulum often becomes a source of gastroesophageal reflux and progressive reflux esophagitis) (Chernousov A.F. et al.)
The simplest complication for diagnosis and treatment is “insufficient” Nissen. In this case, the excessively superficial sutures on the fundoplication cuff are torn, and the latter unfolds (see Fig. 4, a). With the introduction of the laparoscopic technique, the number of inherent complications such as a two-chamber stomach and a twisted cuff has increased several times. Migration of the fundus of the stomach into the chest cavity can occur in the early postoperative period, even at the moment the patient recovers from anesthesia. This happens for a number of reasons, in particular due to unreasonable traction of the shortened esophagus to create a fundoplication cuff below the diaphragm (Fig. 4, d). Inadequate fixation of the fundoplication cuff to the legs of the diaphragm predisposes to the further development of a hiatal hernia or to the development of a paraesophageal hiatal hernia with movement of the splenic flexure of the colon into the chest cavity along the fundoplication cuff (Chernousov A.F. et al.).
The position of gastroenterologists-therapists regarding the treatment of GERD using Nissen fundoplication
Despite the fact that gastroenterologist-therapists around the world say that it is inappropriate to treat GERD surgically using Nissen fundoplication, gastroenterologist-surgeons continue to perform such operations. Postoperative complications occur in 60% of cases.Postoperative lesions of the esophagus:
- inability to burp, regurgitate, vomit
- postoperative achalasia cardia type II
- chest pain.
- syndrome of gas accumulation and bloating of the upper abdomen
- postoperative gastroparesis
- postoperative dumping syndrome.
- bacterial overgrowth syndrome
- bloating of the lower abdomen.
Prof. E.K. Baranskaya talks about complications of Nissen fundoplication surgery (Esophageal-2014 conference)
The position of gastroenterologist-surgeons regarding antireflux operations, including Nissen fundoplications
A large number of antireflux surgeries are not effective. Antireflux surgery should be considered unsuccessful if after which the primary symptoms persist (heartburn, belching, pain, etc.) or new ones appear (dysphagia, pain, bloating, diarrhea, etc.). The persistence of symptoms of reflux esophagitis or their rapid relapse after fundoplication are described in 5-20% of patients after surgery through a laparotomic approach, and in 6-30% of patients after laparoscopic fundoplication. The most common symptoms of ineffective antireflux surgery are gastroesophageal reflux (30-60%) and dysphagia (10-30%), as well as a combination of reflux and dysphagia (about 20%).The variety of reasons for failures and complications of antireflux operations, the technical complexity of repeated interventions and the problematic nature of their good results determine the advisability of concentrating patients with hiatal hernia and reflux esophagitis in specialized hospitals and dictate the need for further clinical research in this area (Chernousov A.F. et al.).
Professional medical work regarding Nissen fundoplication problems
- Lundell L. Surgical treatment of GERD // Experimental and clinical gastroenterology. Special issue. – 2004. – No. 5. – p. 42–45.
- Vasnev O. S. The ups and downs of antireflux surgery // Experimental and clinical gastroenterology. 2010. No. 6. pp. 48–51.
- Chernousov A.F., Khorobrykh T.V., Vetshev F.P. Repeated antireflux operations // Bulletin of surgical gastroenterology. 2011. No. 3. P. 4-15..
- Volchkova I.S. Indicators of daily pH-metry for various types of fundoplications // Bulletin of experimental and clinical surgery. 2012. T. V. No. 1. pp. 168–170.
- Maksimova K.I. Results of endoscopic treatment of hiatal hernia // International Journal of Experimental Education. 2017. No. 3. pp. 39–41.
