Ann Thorac Surg 2007;84:1704-1709. doi:10.1016/j.athoracsur.2007.05.085
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Laparoscopic Clam Shell Partial Fundoplication Achieves Effective Reflux Control With Reduced Postoperative Dysphagia and Gas Bloating
Amgad E. el-Sherif, MD,
Prasad S. Adusumilli, MD,
Brian L. Pettiford, MD,
Thomas A. d’Amato, MD,
Matthew J. Schuchert, MD,
Alicia Clark,
Carmen DiRenzo,
Joshua P. Landreneau,
James D. Luketich, MD,
Rodney J. Landreneau, MD*
The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Accepted for publication May 29, 2007.
* Address correspondence to Dr Landreneau, UPMC Shadyside Medical Center, Suite 715, 5200 Centre Ave, Pittsburgh, PA 15232 (Email: landreneaurj{at}upmc.edu).
Presented at the Poster Session of the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
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Abstract
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Background: We describe a novel laparoscopic "clam shell" partial fundoplication, incorporating a modified Toupet with an anterior fundic flap for the management of medically recalcitrant gastroesophageal reflux disease. We hypothesize that this clam-shell–like mechanism allows a dynamic rather than rigid circumferential antireflux barrier allowing effective reflux control (compared with partial fundoplication) with reduced occurrence of postoperative dysphagia, gas bloating and vagal nerve injury (compared with Nissen fundoplication).
Methods: Between November 2002 and May 2006, 140 patients (82 female; mean age, 53 years) underwent this laparoscopic clam shell fundoplication procedure for medically recalcitrant gastroesophageal reflux disease (n = 94) or large paraesophageal hernias (n = 46). Preoperative invasive studies (endoscopy, manometry, pH monitoring) and noninvasive studies (barium swallow and radionuclide gastroesophageal motility) revealed esophageal dysmotility in 26 patients. Routine barium swallow and radionuclide studies were performed 6 months postoperatively and then at yearly intervals.
Results: There was no mortality or conversions to open procedures. Mean operative time was 45 minutes; median hospital stay was 1 day (range, 1 to 4). Overall control of reflux symptoms was seen in 95% of patients. Postoperative gas bloating and significant dysphagia occurred in only 11% and 6% of patients, respectively. Three patients (2%) experienced postoperative complications (pneumonia, 2; pleural effusion requiring drainage, 1). Postoperative studies demonstrated reflux in 8 patients (5%) and the presence of small hiatal hernias in 5 patients (4%) during a mean follow-up 19 months (range, 7 to 42). Twenty five patients (17%) underwent postoperative esophageal dilation (median dilations, 1; range, 1 to 3) for dysphagia (11 of these patients had preoperative esophageal dysmotility). Five patients underwent repeat fundoplication (recurrent reflux, 2; gas bloating, 1; dysphagia, 2).
Conclusions: Clam shell near-circumferential fundoplication may be considered as an attractive alternative antireflux approach to Nissen fundoplication, particularly among patients at risk for postoperative dysphagia or gas bloating.
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Introduction
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Nissen fundoplication has been reported to reduce gastric compliance, increase minimal gastric distending pressure, and exacerbate discomfort sensation with gastric distention [1]. A recent retrospective review of patients undergoing Nissen fundoplication reported incidences of dysphagia and gas bloating as high as 74% and 70%, respectively [2]. Recent multicenter randomized trials showed more quality of life improvement in the early postoperative period with partial fundoplication compared with Nissen [3].
We recently reported a new laparoscopic "clam shell" partial fundoplication, incorporating a modified Toupet with an anterior fundic flap for the management of medically recalcitrant gastroesophageal reflux disease [4]. Intra-abdominal positive pressure is distributed over the near total circumference of the lower esophagus similar to the Nissen fundoplication procedure, with, however, the clam-shell–like mechanism allowing for a dynamic rather than a rigid circumferential antireflux barrier. This more pliable anatomic arrangement for the fundoplication is also effective in reducing postoperative dysphagia and gas bloating. The potential for vagal nerve injury associated with multiple sutures applied to the distal esophagus to secure the circumferential Nissen wrap and the standard partial Toupet fundoplication is also avoided with this clam shell fundoplication. All of these qualities are important in potentially improving the postoperative quality of life in patients undergoing fundoplication for medically recalcitrant gastroesophageal reflux disease and paraesophageal herniation, particularly among patients with impaired esophageal and or gastric motor dysfunction [5–8].
The technical details related to the performance of this clam shell partial fundoplication are reported here. We also report our analysis of the intermediate-term outcome with this efficient, dynamic hybrid fundoplication.
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Patients and Methods
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We reviewed our series of patients undergoing clam shell partial fundoplication operated on between November 2002 and May 2006. In all, 140 patients (82 female; mean age, 53 years) underwent laparoscopic clam shell procedure. This study was approved by the University of Pittsburgh Institutional Review Board. Because this was a retrospective review, individual consent was waived.
Ninety-four of these patients were referred to us for surgical management of medically recalcitrant gastroesophageal reflux disease. The primary symptoms of these patients were acid reflux/regurgitation in 90 patients (96%), reflux-induced pulmonary symptoms in 4 patients (4%), and dysphagia/sticking of food as an important complaint in 17 (18%).
Forty-six patients were referred for surgical correction of large paraesophageal hernias. Thirty-two (70%) of these patients had symptomatic acid reflux/regurgitation as an important symptom. Forty-one (89%) of these patients also complained of significant chest pain or dysphagia during or immediately after meals.
All patients were evaluated with preoperative endoscopy, manometry, pH monitoring, barium swallow, and radionuclide gastroesophageal motility studies. Preoperative studies confirmed the presence of a large paraesophageal hernia in 46 patients (32%). Esophageal dysmotility (without evidence of achalasia) was identified in 26 of the patients without paraesophageal hernias (27%). Nearly all of the paraesophageal hernia patients had evidence of esophageal motor dysfunction (92%). This esophageal motor dysfunction was defined as lower distal contraction amplitude (<30 mm Hg), decreased peristalsis, or delayed esophageal transit time on radionuclide studies.
Patient follow-up consisted of a routine postoperative visit 2 to 4 weeks after discharge from the hospital, again 6 months after surgery, and then at yearly intervals. The patients were examined at all subsequent visits after their initial postoperative visit with barium esophagrams with upper gastrointestinal contrast roentgenography and esophagogastric nuclear scintigraphic studies to assess esophageal transit and gastric emptying. Symptomatic assessment of their gastroesophageal reflux symptoms, dysphagia scores, and gas bloat symptoms were also performed.
Additionally, the clinical outcomes were assessed further by mailing a questionnaire inquiring into the patients’ perception of change in gastroesophageal reflux symptoms, dysphagia, and gas bloating from before their surgery to their present condition. A profiling of antisecretory medicinal use was obtained along with an inquiry into the utility of these drugs in controlling their gastrointestinal symptoms after surgery. Fisher’s exact test was used for statistical analysis.
Operative Technique
After mobilization of the distal esophagus and gastric fundus, the esophageal bougie established within the esophagus during repair of the hiatal hernia is temporarily retracted back into the esophagus and long curved masher coaxial forceps (Pilling Weck Surgical Instruments; Teleflex Medical Corp, Research Triangle Park, NC) are used to grasp the lateral border of the mobilized gastric fundus. The fundus is then transposed behind the stomach through the retrogastric tunnel created during the earlier described gastric mobilization. After this transfer, the fundus transposed to behind and to the right of the distal esophagus is grasped by a duck-billed endoscopic forceps (Snowden Pencer Surgical Instruments; Cardinal Health Corp, Dublin, OH) in the surgeon’s left hand and released from the masher forceps that had been introduced through a left lower abdominal trocar access site. A 2-0 Surgidac endostitch suture (United States Surgical Corp, Norwalk, CT) is then used to establish the pexy between the mobilized fundus and the upper right aspect of the crural arch at the 11 o’clock position. A second pexy of the mobilized fundus is accomplished between it and the lower aspect of the right crus near the arcuate ligament (Fig 1).
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Fig 1. First gastropexy suture to the right diaphragmatic crura at the 11 o’clock position (A arrow). Second gastropexy suture between mobilized gastric fundus and the crura near the arcuate ligament (B arrow).
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At this point, the gastric fundus remaining in position on the anatomic left side of the gastroesophageal junction is grasped with the masher forceps and pulled upward into position about the lower esophagus. This is necessary to achieve a proper, even height of the posterolateral aspects of the partial fundoplication about the distal esophagus. Once this proper orientation is achieved, suturing of the upper lateral aspect of the left-sided fundus to the lateral wall of the esophagus 3 to 4 cm above the angle of His, and then to the left crus at the 2 o’clock position is accomplished. Care is taken to avoid incorporation of the anterior trunk of the vagus nerve, which courses in an oblique path from left to right in close proximity to the anterior wall of the distal esophagus.
Before tying this triangulation or crown stitch, the 54F bougie is repositioned under laparoscopic vision into the stomach to insure that there is not excessive narrowing of the distal esophagus by the posterior and lateral aspect of the partial fundoplication (Fig 2). This triangulation suture is the only suture in this modified Toupet fundoplication that actually involves direct suturing to the distal esophagus. This avoidance of direct suturing to the esophagus is a central mechanism in reducing the direct trauma to the lower esophagus that may be responsible for the reduction in dysphagia and potential vagal dysfunction after this fundoplication.
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Fig 2. Triangulation, or crown, suture between gastric fundus, distal esophagus, and left crus at the 2 o’clock position on the crural arch.
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The fourth stitch of this modified fundoplication involves the further transfer of the gastric fundus over the anterior aspect of the distal esophagus and suturing it to the right crus at approximately the 11:30 o’clock position on the crural arch (Fig 3). The point of suturing on the fundus is about 5 cm down from the previously established triangulation suture. This maneuver results in the creation of an anterior fundic flap similar to that achieved with an anterior Dor partial fundoplication.
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Fig 3. Transfer of the gastric fundus over the anterior aspect of the distal esophagus and suturing of it to the right crus at approximately the 11:30 o’clock position on the crural arch.
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The final suturing to complete the clam shell partial fundoplication is between the gastric fundus, 5 cm from the Dor fundic on lay and the lower anterior aspect of the gastric fundus that has been mobilized and fixed to the right crus of the diaphragm (Fig 4). This last suture approximation of the fundus to the fundus is positioned intentionally about 2 cm below the gastroesophageal junction to avoid the creation of a circumferential restrictive fundic wrap about the distal esophagus. Effectively, this final suture positioning allows for a dynamic, but near-circumferential, effect of intra-abdominal positive pressure upon the lower esophagus. With deglutition and physiologic gastric distention associated with the occurrence of belching, the valve acts dynamically rather than being a more restrictive circumferential barrier about the distal esophagus (Figs 5 and 6).
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Fig 4. The final suturing to complete the clam shell partial fundoplication is between the gastric fundus, 5 cm from the Dor fundic on lay and the lower anterior aspect of the gastric fundus that has been mobilized and fixed to the right crus of the diaphragm.
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Fig 6. Cross-sectional view of the orientation of the gastric fundus about the distal esophagus. The near total coverage of the distal esophagus by the positioning of the mobilized fundus allows for near-circumferential effect of intra-abdominal pressure upon the lower esophagus. The special orientation of the fundoplication allows for a dynamic rather than static influence upon the lower esophagus leading to reduced dysphagia and gas bloating.
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After inspection of the fundoplication to insure a proper orientation and loose nature about the distal esophagus, the bougie is removed. Hemostasis is assured and carbon dioxide removed from the abdomen after removal of laparoscopic trocar access. Incisional wounds are closed in a routine fashion. The patient is managed without nasogastric tube or urinary catheter drainage after surgery. Antinausea agents are given on schedule rather than on an as-needed basis. Patient-controlled analgesia is utilized the evening of surgery, and the patient is converted to an oral narcotic suspension the next day for control of incisional pain. Postoperative study is limited to a bedside portable chest roentgenogram to insure that important gastric distention is absent. Barium contrast gastrointestinal studies are not routinely performed unless clinically indications are present until 6 months after surgery [9]. The patient is usually discharged the day after surgery on the antiemetic regimen, liquid narcotic analgesics, and a full liquid diet until seen in the office a few weeks after surgery.
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Results
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This clam shell hybrid of a standard Toupet and Dor fundoplication was safely and expediently performed. There was no need for intraoperative conversion to an open procedure to complete the antireflux surgical repair. Mean operative time was 45 minutes, with a range of 30 to 140 minutes. The average hospital stay was slightly less than 2 days, with a range of 1 to 5 days. Symptomatic relief of gastroesophageal reflux symptoms was noted in 95% during the period of follow-up. Gas bloating was reported to be problematic and require medicinal aid in 11% of patients. Seventeen percent of patients experienced postoperative dysphagia. Most of this dysphagia was temporary, resolving within 6 weeks of surgery. Our clinical practice policy to perform early esophageal dilation to reduce the period of recovery from this postoperative dysphagia event resulted in 16 of 25 (64%) of these patients undergoing only one dilation after surgery. As many as three dilations were performed on the remaining 9 patients, with resolution of symptoms in 8. Only 1 of these patients ultimately underwent redo laparoscopic exploration and conversion of the clam shell to a more standard Toupet fundoplication, with significant improvement in dysphagia.
Very few postoperative complications occurred after this laparoscopic clam shell fundoplication experience. Two patients had postoperative pulmonary infiltrates associated with a mild leukocytosis. These patients were begun on a short course of intravenous antibiotics and then transitioned to oral antibiotics at discharge. These were classified as postoperative pneumonia. One patient had an early postoperative pleural effusion managed successfully with thoracentesis.
Postoperative barium studies obtained at a mean interval of 15 months in 112 patients demonstrated mild to moderate gastroesophageal reflux (6%, n = 7). A small hiatal hernia was demonstrated in 8 patients (6%). Three of these 8 hernias were identified among patient operated on for the management of large paraesophageal hernias. Only 1 of these paraesophageal hernia patients demonstrating hiatal herniation was symptomatic. There was evidence of mild delay in esophageal transit of contrast material in 7 patients. One of these 7 patients complained of troublesome dysphagia; another of these patients complained of significant gaseousness and bloating.
Five patients underwent repeat laparoscopic exploration and modification of their fundoplication or correction of the recurrent hiatal herniation at a mean interval of 7 months after their original surgery. There were no complications related to these repeat operations. Symptomatic and anatomic improvement was noted in all patient after revision of their partial fundoplication to achieve greater reflux control or reduced circumscription of the distal esophagus.
Twenty-four percent of patients were noted in follow-up to have been prescribed antisecretory/proton pump inhibitor medications by primary care physicians for a variety of gastrointestinal complaints. Only 5% of patients were depended upon these agents for control of reflux or other vague gastrointestinal symptoms. These findings are similar to those reported by others [10, 11].
Retrospective Postoperative Clam Shell Fundoplication Symptom Survey
A retrospective blinded mailing survey was sent out to all patients by our thoracic surgical department. One hundred three patients (73% of total patient cohort) responded to this survey. Responders had a mean follow-up period of 17 months (range, 3 to 42). These patients were asked to rate the severity of heart burn, dysphagia, and gas bloating symptoms on a scale of 1 to 10 (no symptoms to severe symptoms) before and after their clam shell partial fundoplication. Symptoms were graded for the purpose of this survey as follows: none to minimal equaling a score of 1 to 3; moderate equaling 4 to 6; and severe as greater than 7 on the visual analogue scale. These responders reported an overall improved control of reflux symptoms at 96%. No to minimal reflux symptoms were noted in 72% of responders, and infrequent moderate symptoms less than that seen before surgery in 24% of responders. Only 5% of responding patients complained of a lack of improvement or worsening of reflux symptoms compared with their preoperative condition. The overall improvement in reflux symptoms was very significant (p < 0.0001). Similarly, all responders, which did include paraesophageal hernia patients, reported an improvement in dysphagia scores, with only 8% having moderate dysphagia compared with 37% of patients complaining of severe dysphagia preoperatively (p < 0.001). Interestingly, 11% of responders reported gas bloating to be severe after their surgery compared with 71% of responders reporting severe gas and bloating symptoms before surgery (p < 0.001; Fig 7).
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Fig 7. Change in patient symptoms of acid reflux, dysphagia, and gas bloating after clam shell fundoplication. (Gray bars = before surgery; black bars = after surgery.)
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These responding patients also reported their satisfaction with the outcome of their antireflux surgery as a part of the questionnaire on a similar 1 to 10 visual analogue scale. Overall satisfaction was noted in 91% of patients, with a mean score of 3 on this 1 to 10 scale.
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Comment
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The primary goal of this report is to describe the technical details of a new partial fundoplication approach to symptomatic gastroesophageal reflux disease. This intermediate-term clinical evaluation of this dynamic, near-circumferential, clam shell like fundoplication has provided promising results.
Nissen fundoplication has a high long-term control of reflux, ranging from 85% to 95% [12]. Although its efficacy is well documented in terms of gastroesophageal reflux control, the postoperative sequelae of dysphagia and gas bloating related to the restrictive nature of the circumferential wrap about the distal esophagus and possible vagal nerve injury occurring during the creation of the fundoplication frequently result [13].
An increased risk of antireflux barrier failure reported with the Toupet 270-degree partial fundoplication compared with the 360-degree Nissen fundoplication procedure has led many surgeons to continue reliance upon the Nissen procedure for surgical management of medically recalcitrant gastroesophageal reflux patients and patients with important paraesophageal herniation [14, 15]. The risk of relatively less efficient control of acid reflux with the Toupet procedure is often considered as a reasonable compromise decision when approaching symptomatic gastroesophageal reflux patients with impaired esophagogastric motility.
Although the jury is still out on this hybrid clam shell fundoplication, many features of this technique may result in an improved overall quality of life for our patients referred for medically recalcitrant gastroesophageal reflux disease. The addition of the anterior Dor fundoplication like flap potentially enhances one of the primary mechanisms of antireflux control of all related surgical procedures. This being enhancement of the effect of intra-abdominal positive pressure upon the lower esophageal segment within the fundoplication. The reduction in the absolute number of sutures applied about the distal esophagus and proximal stomach required to create this modified Toupet fundoplication orientation can minimize the risk of vagal nerve injury and postoperative trauma to the sensitive physiology of the distal esophagus, gastroesophageal junction, and proximal fundus of the stomach [4]. The durability of the technical orientation of gastroesophageal tissues and the hiatal hernia repair integral to the creation of this clam shell fundoplication appears acceptable at an intermediate endpoint of clinical follow-up.
The clinical results seen with this clam shell fundoplication with regard to gastroesophageal reflux control, postoperative dysphagia, and gas bloating occurrence is also gratifying at this interim analysis. Future follow-up of the results with this hybrid approach to fundoplication will be necessary to determine the long-term utility of this procedure.
In conclusion, clam shell near-circumferential fundoplication may be considered as an attractive alternative antireflux approach to Nissen fundoplication, particularly among patients at risk for postoperative dysphagia or gas-bloating.
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Acknowledgments
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The authors wish to acknowledge the service of Mr Ron Filer in the creation of the drawings.
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References
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Abstract
Introduction
