Intrathoracic migration of the wrap after laparoscopic Nissen fundoplication: radiologic evaluation

The purpose of our study was to evaluate the different types of postoperative herniation of the wrap into the thorax after laparoscopic Nissen fundoplication, to propose a clear radiologic definition, and to establish their respective frequencies.

Two hundred twenty-six consecutive patients who underwent laparoscopic Nissen fundoplication were studied prospectively. All patients underwent an upper gastrointestinal series before surgery and on the first postoperative day. Radiologic follow-up performed yearly after surgery in 148 patients (65%) consisted of a double-contrast upper gastrointestinal series. Intrathoracic migration of the wrap was diagnosed on radiography when the intact fundoplication wrap herniated partially or entirely through the esophageal hiatus of the diaphragm. The kappa statistic was used to assess interobserver agreement.

Of the 148 upper gastrointestinal series, 44 intrathoracic migrations (30%) were diagnosed. These examinations were reviewed and allowed us to differentiate two types of migrations. Type I (31 patients) consists of a paraesophageal hernia of a portion of the wrap through the esophageal hiatus with the esogastric junction remaining below the diaphragm. Type II (13 patients) is diagnosed when the entire fundoplication herniates through the hiatus with the gastroesophageal junction located at or above the level of the diaphragm.

Intrathoracic migration is an important complication of laparoscopic Nissen fundoplication. Most migrations are small and asymptomatic. We propose a simple and reproducible radiologic definition of two different types of intrathoracic migration of the wrap observed after laparoscopic Nissen fundoplication.