Overview
Definition:
Anterior fundoplication, specifically tailored for patients with pre-existing or co-existing poor gastric motility, involves creating a partial fundic wrap anterior to the esophagus to treat gastroesophageal reflux disease (GERD) or hiatal hernia
The modification aims to minimize further impairment of gastric emptying, a critical consideration in this patient population.
Epidemiology:
GERD affects a significant portion of the population
Patients with comorbid conditions like diabetes mellitus, post-vagotomy states, or idiopathic gastroparesis represent a subset requiring specialized surgical approaches
The prevalence of these comorbidities increases with age.
Clinical Significance:
Managing GERD in patients with compromised gastric motility is challenging
Standard fundoplication can exacerbate symptoms like early satiety, bloating, and nausea due to further delayed gastric emptying
Anterior fundoplication offers a potentially less constrictive wrap, aiming to balance reflux control with gastric function preservation, crucial for improving quality of life and preventing malnutrition.
Indications
Refractory Gerd:
Medically refractory GERD in patients with documented impaired gastric motility, where conservative management has failed.
Hiatal Hernia With Motility Issues:
Large paraesophageal or sliding hiatal hernia associated with significant reflux symptoms and objective evidence of poor gastric emptying.
Post Surgical Patients:
Patients with prior gastric surgery (e.g., partial gastrectomy, truncal vagotomy) who develop GERD and have demonstrated delayed gastric emptying.
Preoperative Assessment
History Taking:
Detailed history of GERD symptoms (heartburn, regurgitation, dysphagia, chest pain), previous abdominal surgeries, and symptoms suggestive of gastroparesis (early satiety, postprandial fullness, nausea, vomiting, abdominal bloating)
Explore diabetes, neurological conditions, or medications affecting motility.
Physical Examination:
General examination for signs of malnutrition or dehydration
Abdominal examination for distension, tenderness, or masses
Assess for signs of systemic illness.
Diagnostic Investigations:
Upper gastrointestinal endoscopy to assess for esophagitis, Barrett's esophagus, and rule out malignancy
Esophageal manometry to evaluate lower esophageal sphincter (LES) pressure and esophageal motility
24-hour pH monitoring to confirm acid reflux
Gastric emptying study (scintigraphy or breath test) is MANDATORY to objectively quantify gastric motility
Upper GI series (barium swallow) can assess anatomy and gross motility patterns.
Surgical Approach
Patient Selection:
Careful selection of patients is paramount
Patients with severe, irreversible gastroparesis may not be surgical candidates or may require combined procedures
Aim for patients with moderate motility issues or those where reflux is the dominant symptom.
Procedure Details:
Laparoscopic approach is preferred
The gastroesophageal junction is mobilized
A partial anterior wrap (typically 180-240 degrees) is created using the gastric fundus, positioned anterior to the esophagus
The wrap should be loose enough to avoid significant gastric outlet obstruction but tight enough to provide adequate anti-reflux competence
Avoid complete (360-degree) or overly tight wraps.
Intraoperative Considerations:
Meticulous dissection to preserve gastric blood supply
Careful assessment of wrap tension
Intraoperative endoscopy or manometry can aid in optimizing wrap construction
Consider concomitant pyloric intervention (e.g., pyloromyotomy) in select cases of severe gastroparesis if deemed appropriate and not contra-indicated.
Postoperative Care
Initial Management:
NPO initially, advancing to clear liquids as tolerated
Close monitoring for nausea, vomiting, and abdominal distension, which may indicate worsening gastric stasis or mechanical obstruction.
Medications:
Prokinetic agents (e.g., metoclopramide, domperidone if available and indicated) may be initiated judiciously to aid gastric emptying
Acid suppression therapy (PPIs) continues
Avoid opioids due to their pro-motility depressing effects.
Dietary Modifications:
Small, frequent meals with a diet low in fat and fiber
Avoid carbonated beverages and gas-producing foods
Nutritional support may be required if oral intake is insufficient.
Complications
Early Complications:
Bleeding
Infection
Injury to adjacent organs
Anastomotic leak (rare)
Worsening nausea, vomiting, or abdominal distension due to impaired gastric emptying
Dysphagia.
Late Complications:
Recurrent GERD due to inadequate wrap
Gastric outlet obstruction
Dumping syndrome (less common with anterior wraps but possible)
Persistent gastroparesis symptoms
Diarrhea
Suture line dehiscence.
Prevention Strategies:
Thorough preoperative assessment of gastric motility
Judicious wrap construction to avoid excessive tightness
Careful intraoperative dissection
Aggressive postoperative management of nausea and vomiting
Early mobilization
Judicious use of prokinetic agents
Close dietary counseling.
Prognosis
Factors Affecting Prognosis:
Severity of underlying gastroparesis
Technical execution of the surgical procedure
Patient compliance with postoperative dietary and medication regimens
Presence of comorbidities.
Outcomes:
In well-selected patients, anterior fundoplication can effectively control reflux symptoms while minimizing the exacerbation of gastric motility issues
However, outcomes are generally less predictable than in patients with normal gastric function
Some degree of residual or worsened gastroparetic symptoms may persist.
Follow Up:
Regular clinical follow-up is essential
Serial assessment of GERD symptoms and gastric emptying status
Endoscopic surveillance may be indicated for Barrett's esophagus
Long-term management may involve a combination of diet, medication, and potentially further surgical intervention if symptoms are refractory.
Key Points
Exam Focus:
The critical differentiating factor for anterior fundoplication in poor motility is the MANDATORY preoperative assessment of gastric emptying
Standard fundoplication is contraindicated or carries high risk
Anterior, loose wraps are preferred.
Clinical Pearls:
Always consider the patient's underlying gastric motility before proceeding with any anti-reflux surgery
A gastric emptying study is non-negotiable
If severe gastroparesis exists, consider gastric pacing or other pro-motility interventions as primary or adjunctive therapy.
Common Mistakes:
Performing a standard Nissen fundoplication in a patient with significant gastroparesis
Failing to obtain objective evidence of gastric motility preoperatively
Creating an overly tight fundic wrap
Underestimating the need for postoperative prokinetic support and dietary modification.