Failed Fundoplication: GI Perspective

Philip Katz MD MACG, AGAF

Professor of Medicine
Director GI function Laboratories
Weill Cornell Medicine

Disclosure

• Consultant Phathom Pharma

1
 General Principles
• 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

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 What do I need?
• All pre op testing
• Operative note (or clear equivalent of what operation)
• Any post op testing prior to visit
• If multiple failed fundoplication not as helpful to know
details

Nissen/Partial/Normal

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 Anatomy of Failure

Herniated Wrap

disruption of the crural repair or

failure to perform the initial wrap
over a tension-free segment
of intra-abdominal esophagus.

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 Slipped Nissen
stomach slipping through the
fundoplication
or incorrect positioning of the
wrap around the stomach at
original operation

Herniated/Slipped Wrap

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5
 Paraesophageal Hernia

Incomplete hiatal closure

11

Paraesophageal Hernia

12

6
 Two Compartment Stomach

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Twisted (para?)

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7
 Gas-bloat Syndrome

• Bloating, abdominal distention, early

satiety, nausea, upper abdominal pain,
flatulence, inability to belch, and inability
to vomit.

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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.

16

8
 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

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Gas Bloat Management

• dietary modifications to avoid gas-producing foods
and carbination
• eating slower to avoid aerophagia,
• cessation of smoking,
• gas-reducing agents (5)
• prokinetic drugs if gastric emptying delayed
• Biofeedback?

18

9
 Gas Bloat
• Rarely dilate
• G-POEM if gastric emptying severe
• Take down redo if patient runs out of patience

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Dysphagia
• Too tight for their functional esophageal pump,
• Previously unrecognized achalasia
• Healed peptic stricture
• Paraesophageal hernia
• Excessively tight crural closure
• Slipped fundoplication (into chest) with recurrent hernia
• Distal migration of the wrap onto the stomach

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10
 Dysphagia
• All have for several weeks
• 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

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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.

22

11
 Diarrhea
• Nutrition
• SIBO testing/rifaximin empiric
• Antidiarrheals
May spontaneously remit

23

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

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 THE END

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