Difference between revisions of "Esophagastric fundoplication"

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{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT (DLT if thoracic approach)
| lines_access = Large bore PIV
± Arterial Line
| monitors = Standard
| considerations_preoperative = Patients often Obese
| considerations_intraoperative = RSI frequently indicated
| considerations_postoperative = ± epidural or PCA
}}


'''Esophagastric fundoplication''' is a type of procedure where the stomach is wrapped around the lower segment of the esophagus in order to prevent reflux or treat hiatal hernias. Multiple variants exist, and approach to surgery can be transabdominal, transthoracic, or laparoscopic. See [[Belsey Mark fundoplication|Belsey Mark Fundoplication]] for anesthetic management of this variant, which is discussed separately.
== Overview ==
=== Indications ===
* Esophageal reflux refractory to medical management
* Hiatal hernia
=== Surgical procedure ===
* Multiple variants essentially wrapping the stomach fully or partially around the lower segment of the esophagus
* Nissen Fundoplication, where the stomach is wrapped fully around the esophagus, is the standard that other variants are compared to
* Nissen results in full 360 degree wrap of the stomach around the esophagus, while the other approaches are partial wraps
* Approach can be transabdominal, transthoracic, or laparoscopic
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Many patients have co-morbidities including obesity, careful evaluation of airway for signs of difficult intubation (Mallampati, neck thickness, thyromental distsance)
|-
|Neurologic
|Standard evaluation
|-
|Cardiovascular
|Standard evaluation
|-
|Pulmonary
|Standard evaluation
|-
|Gastrointestinal
|Check for active reflux or nausea/vomiting that would require RSI
|}
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
* CBC
* BMP
* ± PTT/INR
* ± Type and Screen
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Aspiration precautions if severe GERD
* Check for ERAS protocol
* ± Benzodiazepine premedication
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
* N/A if laparoscopic approach
== Intraoperative management ==
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* Standard monitors
* Large bore PIV
* ± Arterial Line depending on patient comorbidities
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
* RSI for active reflux or nausea
* Otherwise standard induction with ETT
* DLT if thoracic approach
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Supine
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* Standard maintenance
* If epidural is in place, can consider combined approach with intra-op epidural infusion
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
* Routine. Ensure well suctioned of any gastric contents.
== Postoperative management ==
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* PACU
* Floor admission
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
* If open approach, can consider epidural vs PCA for post-op pain control
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Dysphagia
* Recurrent hernia or reflux
* Splenic laceration
* Vagus nerve injury
* Atelectasis
* Esophageal or gastric perforation
* Hemorrhage
* Pneumothorax
* Capnomediastinum
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Nissen (Toupet)
!Laparscopic Nissen
!Hill
|-
|Unique considerations
|Midline abdominal incision
|Laparoscopic incisions
|Midline abdominal incision
|-
|Position
|Supine
|Supine, split legs
|Supine, split legs
|-
|Surgical time
|1-2 hrs
|1-2 hrs
|1-2 hrs
|-
|EBL
|100-150 mL
|50mL
|100-150mL
|-
|Postoperative disposition
|PACU then floor
|PACU then floor
|PACU then floor
|-
|Pain management
|Consider thoracic/lumbar epidural vs PCA
|Multimodal pain management
|Consider thoracic/lumbar epidural vs PCA
|-
|Potential complications
|See above
|See above
|See above
|}
== References ==
<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|pages=545-546}}</ref><ref>Joubert KD, Betzold RD, Steliga MA: Successful treatment of esophageal necrosis secondary to acute type B aortic dissection. Ann Thorac Surg 2016; 102(6):e547-9.</ref><ref>Patel A, Young LB, Rundback JH: Percutaneous esophagogastrostomy creation for gastric bypass reversal. J Vasc Interv Radiol 2016; 27(10):1552-3.</ref><ref>Weber C, Davis CS, Shankaran V, et al: Hiatal hernias: a review of the pathophysiologic theories and implication for research. Surg Endosc 2011; 25(10):3149-53.</ref>
[[Category:Surgical procedures]]

Latest revision as of 22:08, 23 February 2024

Esophagastric fundoplication
Anesthesia type

General

Airway

ETT (DLT if thoracic approach)

Lines and access

Large bore PIV ± Arterial Line

Monitors

Standard

Primary anesthetic considerations
Preoperative

Patients often Obese

Intraoperative

RSI frequently indicated

Postoperative

± epidural or PCA

Article quality
Editor rating
Comprehensive
User likes
0

Esophagastric fundoplication is a type of procedure where the stomach is wrapped around the lower segment of the esophagus in order to prevent reflux or treat hiatal hernias. Multiple variants exist, and approach to surgery can be transabdominal, transthoracic, or laparoscopic. See Belsey Mark Fundoplication for anesthetic management of this variant, which is discussed separately.

Overview

Indications

  • Esophageal reflux refractory to medical management
  • Hiatal hernia

Surgical procedure

  • Multiple variants essentially wrapping the stomach fully or partially around the lower segment of the esophagus
  • Nissen Fundoplication, where the stomach is wrapped fully around the esophagus, is the standard that other variants are compared to
  • Nissen results in full 360 degree wrap of the stomach around the esophagus, while the other approaches are partial wraps
  • Approach can be transabdominal, transthoracic, or laparoscopic

Preoperative management

Patient evaluation

System Considerations
Airway Many patients have co-morbidities including obesity, careful evaluation of airway for signs of difficult intubation (Mallampati, neck thickness, thyromental distsance)
Neurologic Standard evaluation
Cardiovascular Standard evaluation
Pulmonary Standard evaluation
Gastrointestinal Check for active reflux or nausea/vomiting that would require RSI

Labs and studies

  • CBC
  • BMP
  • ± PTT/INR
  • ± Type and Screen

Operating room setup

Patient preparation and premedication

  • Aspiration precautions if severe GERD
  • Check for ERAS protocol
  • ± Benzodiazepine premedication

Regional and neuraxial techniques

  • N/A if laparoscopic approach

Intraoperative management

Monitoring and access

  • Standard monitors
  • Large bore PIV
  • ± Arterial Line depending on patient comorbidities

Induction and airway management

  • RSI for active reflux or nausea
  • Otherwise standard induction with ETT
  • DLT if thoracic approach

Positioning

  • Supine

Maintenance and surgical considerations

  • Standard maintenance
  • If epidural is in place, can consider combined approach with intra-op epidural infusion

Emergence

  • Routine. Ensure well suctioned of any gastric contents.

Postoperative management

Disposition

  • PACU
  • Floor admission

Pain management

  • If open approach, can consider epidural vs PCA for post-op pain control

Potential complications

  • Dysphagia
  • Recurrent hernia or reflux
  • Splenic laceration
  • Vagus nerve injury
  • Atelectasis
  • Esophageal or gastric perforation
  • Hemorrhage
  • Pneumothorax
  • Capnomediastinum

Procedure variants

Nissen (Toupet) Laparscopic Nissen Hill
Unique considerations Midline abdominal incision Laparoscopic incisions Midline abdominal incision
Position Supine Supine, split legs Supine, split legs
Surgical time 1-2 hrs 1-2 hrs 1-2 hrs
EBL 100-150 mL 50mL 100-150mL
Postoperative disposition PACU then floor PACU then floor PACU then floor
Pain management Consider thoracic/lumbar epidural vs PCA Multimodal pain management Consider thoracic/lumbar epidural vs PCA
Potential complications See above See above See above

References

[1][2][3][4]

  1. ↑ Jaffe, Richard. Anesthesiologist's Manual of Surgical Procedures. pp. 545–546.
  2. ↑ Joubert KD, Betzold RD, Steliga MA: Successful treatment of esophageal necrosis secondary to acute type B aortic dissection. Ann Thorac Surg 2016; 102(6):e547-9.
  3. ↑ Patel A, Young LB, Rundback JH: Percutaneous esophagogastrostomy creation for gastric bypass reversal. J Vasc Interv Radiol 2016; 27(10):1552-3.
  4. ↑ Weber C, Davis CS, Shankaran V, et al: Hiatal hernias: a review of the pathophysiologic theories and implication for research. Surg Endosc 2011; 25(10):3149-53.

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