A gastroenterologist’s view of post-surgical complications

George Triadafilopoulos, MDClinical Professor of Medicine

Stanford University School of Medicine

MISS, Salt Lake, UT, 2.21.2012

Outline

• What can happen

• How do we find out

• What can we do about it

What can happen…

Reasons for revisional surgery

Dysphagia Reflux Herniation Atypical0

10

20

30

40

50

60

48

33

15

4

%

N=109 pts

Lamb et al. Br J Surg. 2009;96(4):391-7

Esophagus – Diagnostic Steps

Barium studies

Intra-thoracic wrap migration

Revisional surgery

Endoscopy: Intact fundoplication

Snug scope upon retroflexion

Elongated intra-abdominal sphincter

Intra-thoracic wrap

Recurrence of hiatal hernia

Lax fundoplication with GERD and Barrett’s esophagus

LaxityFree reflux and Barrett’sesophagus

Barrett’s esophagus

Abnormal esophageal acid exposure despite previous fundoplication and

twice daily PPI

57 yo woman post Nissen with recurrent GERD symptoms; no hiatal hernia/esophagitis; LESP: 10mmHg; regurgitation despite PPI

% pH<4: 8.3DeMeester: 28.8Study on esomeprazole 40mg bid

Other (very important) conditions

Eosinophilic esophagitis Achalasia Barrett’s adenocarcinoma

Esophago-gastric fistula: Intact Nissen, recurrentGER

Multichannel intraluminal impedance assesses esophageal

clearance

Recurrent, persistent, or new onset of dysphagia after

antireflux surgery

3 possibilities:

• Patients with signs of obstruction at or above the GEJ suspicious of “crural stenosis” (40%).

• Patients with signs of total or partial migration of the wrap intra-thoracically (50%).

• Patients in whom the hiatal closure is radiologically assessed to be correct with a supposed “stenosis of the wrap” (10%).

Pneumatic dilation for crural stenosis: 85% successful

Stomach/Intestine – Diagnostic Steps

Gastric emptying study in gastroparesis

Gas-Bloat: Nissen vs Toupet fundoplication

Gas-bloat symptoms post NissenDigestive and Liver Disease 39 (2007) 312–318

Gas-bloat symptoms post ToupetDigestive and Liver Disease 39 (2007) 312–318

Bloating before and after fundoplication +/- pyloroplasty

World J Surg. 2007;31(2):332-6

*

Concomitant pyloroplasty improves gastric emptying in GERD patients with gastroparesis

World J Surg. 2007;31(2):332-6

Medical therapy of mild to moderate gastroparesis

• Dietary modification• Liquid supplements• Metoclopramide• Domperidone• Erythromycin• Antiemetics• PPI

Camilleri, M. N Engl J Med 2007; 356:820

Medical therapy of severe gastroparesis

• Pyloric BoTox injection• Enterra• Venting PEG & feeding PEJ• Subtotal gastrectomy & Roux-en-Y gastro-

jejunostomy

Camilleri, M. N Engl J Med 2007; 356:820

Pyloric motility and BoTox injection for gastroparesis

Pyloric BoTox for gastroparesis

GES Symptoms0

10

20

30

40

50

60

5255

% improvement at 2 months, n=6

Ezzedine et al. GIE. 2002;55:920-3

Enterra® for refractory post-surgical gastroparesis

GES Symptoms0

10

20

30

40

50

60

4853

% improvement at 60 months n=31

McCallum et al .CGH 2011

Small bowel bacterial overgrowth

• Diagnosed by lactulose breath test (early rise in hydrogen production)

• Treatment with antibiotics– Rifaximin– Augmentin plus metronidazole– Septra plus metronidazole– Norfloxacin

Conclusions

• Post-fundoplication syndromes are multifaceted and require thorough evaluation

• Revisional surgery may be needed

• Medical therapy for gas bloat and gastroparesis is complex and suboptimal