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[Intestinal obstruction after Nissen's fundo-plication]
Insights
Nissen fundoplication for reflux can cause severe obstruction, a rare but life-threatening complication. This surgical risk, leading to intestinal ischemia and death in most cases, requires careful patient counseling and specific surgical techniques.
Area of Science:
- Gastroenterology
- Pediatric Surgery
- Surgical Complications
Background:
- Nissen fundoplication is a primary surgical treatment for gastroesophageal reflux.
- While effective, it carries risks including dysphagia and gas bloat syndrome.
- Intestinal obstruction is a rare but severe complication of this procedure.
Observation:
- This report details 6 cases of Nissen fundoplication complications.
- Four cases involved children with prior esophageal atresia or severe apnea.
- Two adult cases presented with gastric perforation post-fundoplication.
Findings:
- Three pediatric cases experienced fatal intestinal ischemia within hours of obstruction.
- One child required emergent gastric tube insertion and later re-operation.
- Adults presented with gastric perforation at 7 days and 9 months post-surgery, with one fatality.
- Overall mortality was 4 out of 6 cases.
Implications:
- Nissen fundoplication complications, particularly obstruction, have high morbidity and mortality.
- Emergent gastric tube insertion can decompress the digestive tract but may not prevent recurrence.
- Informed consent regarding obstruction risks is crucial for patients and parents.
- Preventive surgical strategies include a submesocolic approach avoiding small bowel exposure.
Abstract:
Nissen's fundal plication is acknowledged as the most effective procedure to suppress gastroesophageal reflux. It entails some morbidity (dysphagia, gas bloat syndrome), in which obstruction is the least frequently evoked but most severe risk. We report about 6 cases (4 children and 2 adults). The 4 children had been operated 3 times during the first few months of life, and their reflux was secondary to the cure of atresia of the esophagus in 2 cases, and caused severe apneas in 1 case, a former premature infant. In three cases, the obstruction was complicated within a few hours by intestinal ischemia causing death. In one case, the emergent insertion of a gastric tube allowed the decompression of the digestive tract and second surgery; the obstruction recurred 2 months later, with no postoperative complications. Two adults (aged 64 and 66) presented with gastric perforation 7 days and 9 months after fundal pliction; one of them died. These cases show how serious these obstructions are (4 deaths/6 cases). The emergent measure in such cases consists of inserting a gastric tube, although which may be impossible (1 case). The patients and their parents must be informed of this risk of complication and of its expressions. Prevention is based on a strictly submesocolic surgical approach, without any exposure of the small bowel.