There has been a huge increase in antireflux operations over the last two decades. The emergence of minimally invasive surgery has led to a widening of surgical indications for the operation. Reflux disease remains a functional disorder and it must still be assessed with objectivity if unequivocal evidence of mucosal damage within the esophagus is to be documented before indicating a medical treatment or a surgical approach. As hiatal hernias and reflux esophagitis have been closely associated over the last half century, complications in their surgical management will be treated together.

Preoperative Complications

Gastroesophageal reflux disease (GERD) is a pathologic reflux disorder that causes mucosal damage. The presence of symptoms suggestive of reflux without any mucosal alteration is considered a functional reflux disorder.¹ As all humans have physiologic episodes of reflux, the diagnosis, to be clear, must be based on objective criteria if a wrong diagnosis with its unhappy results is to be avoided. Operations should not be planned on the basis of symptoms, alone, as they bear little relationship to the degree of damage present in the esophagus. At a minimum, radiologic and endoscopic documentation of the disease must be obtained. Classification of damage using the MUSE (Metaplasia, Ulcerations, Stricturing, and Erosions) classification or the Los Angeles classification are considered objective as they only consider mucosal breaks in the esophagus to be evidence of damage (Table 32-1).

Complications during the Operation

Most of the antireflux operations completed today are by laparoscopic approach. The reported morbidity varies from 4% to 7% with a 0.1% mortality.² Morbidity, however, even if these new approaches have modified its prevalence, must be looked at independently of open abdominal, thoracic, or minimally invasive incisions. Open repairs, especially those utilizing laparotomy, are thought to produce more splenic trauma, primarily during mobilization of the gastric fundus for fundoplication or by simple traction on the omentum causing avulsion of adhesions on the splenic capsule. The open approach is also associated with a greater number of incisional hernias. However, the transition from open surgery to minimally invasive operations has not resulted in morbidity becoming part of the past. Looking at medical liability issues in Canada in 109 closed liability files allowed us to document that while 37% of these files before the era of minimally invasive surgery were related to antireflux operations, that proportion increased to 76% during the 15-year period following the appearance of the new approach. Central issues for complaint were mostly iatrogenic injuries incurred during the operation. Organ perforations (esophagus, stomach, small and large bowel) were the most frequent complications. Vagal nerve injuries were responsible for 7% of these files, whereas major vessel (vena cava, left hepatic vein, aorta, inferior pulmonary vein) injuries accounted for 8%. Splenic injury also remained a major source of intraoperative complications. These lesions emphasize the need for conversion readiness whenever immediate control of bleeding is needed. Although a 1% to 3% prevalence of splenic injury is reported during open repairs^3,4 in a much larger cohort of patients treated laparoscopically, the overall frequency of splenic injury was only 0.2%.⁵

Esophageal perforation results from blind dissection of the posterior intra-abdominal esophagus. Urschel⁶ reported it in 2% of operated patients. Zaninotto et al.⁷ reported the complication in 1% of patients with a minimally invasive approach. Dissection under direct vision with palpation when open, or careful visual mobilization during laparoscopy, should prevent the problem. When present, the traumatized organ must be repaired primarily, observing all the principles of esophageal perforation repair. Healthy tissue coverage over the repair is essential. Inadvertent gastrotomy or enterotomy usually results from inappropriate manipulation or from the excessive use of the cautery. In Urschel’s report, gastroesophageal leaks occurred in 2% of open antireflux surgery and this increased to 8% if previous hiatal surgery had been completed.

Nerve injury to both vagal trunks can occur during the esophageal dissection or when constructing the fundic wrap around the esophagus. Reoperations are always seen as a major risk for vagal injury, especially those with a thoracic approach. When this occurs, delayed gastric emptying with gastric outlet obstruction can be expected. Pyloric dilatation or an eventual pyloromyotomy or pyloroplasty can be planned after a reasonable attempt at conservative management. Pneumothorax may occur when an abdominal or a minimally invasive approach is used, or when using a left thoracic incision, and consequently is part of the repair. Entry into the right chest through the middle mediastinum behind the heart is considered an important part of the operation for repair of the hiatus for both antireflux and massive paraesophageal hernia repairs. This ensures proper identification of the right diaphragmatic crus for proper suture positioning on both cruses behind the esophagus. The additional use of mesh is not indicated with this technique.

Postoperative Complications

Immediate: Intra-abdominal Infections

Complications resulting in fistula formation are rare but may result from unrecognized injuries during the dissection or from poorly repaired injuries during the operation. Thick stitches on the wall of the esophagogastric junction can produce similar results when transmural necrosis occurs at their level. Prolonged ileus and progressive abdominal or mediastinal sepsis must be managed aggressively by reoperation to obtain control of the contamination site. Emergency esophagectomy or gastrectomy may even be indicated to control the septic condition.

Bleeding, although rare, may result from direct injury to the liver or spleen or from poor hemostasis on the gastrosplenic vessels.

Early

Dysphagia following antireflux operations usually results from unmeasured tension exerted by the fundic wrap on the esophageal wall. Although dysphagia may be transient when influenced by postoperative inflammation and with the repair, it may persist over time if the tension exerted affects the integrity of the esophageal lumen. This is usually prevented by using a 48F or 50F bougie within the esophageal lumen during the repair. Severe dysphagia can also result from tight crural sutures behind the esophagus. This is rarely seen when the index finger passes easily between the newly repaired hiatus and the esophageal wall at the end of the repair. A total fundoplication made too long will result in the same obstructive effects. Reoperation becomes indicated if complete obstruction is present or if significant obstruction persists over time. Acute early herniation of the fundoplication or even major portions of the stomach may occur after complete dissection of the hiatus with division of the phrenoesophageal attachments. Tenuous suture repair of the hiatus with significant intra-abdominal pressure may simply push the stomach above the hiatus. This is seen mostly in obese patients or in patients who produce sudden pressure increases immediately after the operation. The presence of shortened esophagus, as seen with stricture or in patients with massive hernias or with a circumferential Barrett esophagus, is usually the result of a repair under tension if a standard antireflux operation has been used: early migration in the mediastinum is frequently seen in these patients.

Late

Failure of the antireflux repair over time may be secondary to wrap disruption or malposition of the wrap around the gastric smaller curvature. A slipped fundoplication from a periesophageal position to a perigastric position creates an hourglass stomach with reflux symptoms and dysphagia. Pressure of the fundoplication on a tightly closed hiatus may produce this complication, especially if the wrap has not been fixed to the esophageal wall and if the esophagus is shortened. Complete transhiatal herniation of the wrap usually results from a deficient hiatal repair or from an esophagus shortened by disease. If a partial fundoplication has been completed, reflux disease will result with the fundoplication in the chest. If a total fundoplication has been used, it may still offer good reflux control even if in the mediastinum. Proper gastric drainage is important in that situation and the hiatus must be widely open to allow easy emptying of the herniated stomach.

Complications Related to Massive Hernia Repair

Massive paraesophageal hernias show a failure rate of 10% to 18% when an open abdominal approach is used. Maziak and Pearson^8,9 when using an elongation gastroplasty reported a recurrence rate of 4%. Laparoscopic repair of paraesophageal hernias shows an early recurrence rate of 15% to 66%. The three significant aspects of massive hernia repairs that are still open to discussion in the surgical literature are: first, the notion of esophageal shortening, second, the prevalence of reflux disease and its evolution and third, the large hiatal defect. These three factors are probably influential in the early failure rate of the operations selected to treat them.

Primary esophageal dysfunction is seen at the pharyngoesophageal junction or on the esophageal body and at the esophagogastric junction. Cricopharyngeal myotomy is the preferred treatment offered to patients with oropharyngeal dysphagia of various causes. Esophageal body myotomy and the modified Heller myotomy aim at controlling symptoms resulting from primary esophageal motor disorders. These operations, even if successful in the majority of patients, can be responsible for significant morbidity and even mortality.

Operations on the Pharyngoesophageal Sphincter

Idiopathic Oropharyngeal Dysphagia

This form of idiopathic dysphagia affects the cricopharyngeus but has no neurologic or muscular condition to explain it. It is seen as an obstructive upper esophageal sphincter by itself or accompanied by its complication, the pharyngoesophageal or Zenker diverticulum. The cause for the muscle abnormality resulting in this constrictive and obstructive condition remains unknown. In the previous era, when no antibiotics were available, it was considered a treacherous problem where inflammation, perforation, mediastinitis, tracheoesophageal fistulas, and carcinoma formation could be expected when untreated. These complications are rarely seen today. Still, 61% of patients treated today complain of dysphagia and 17% mention aspiration episodes and pulmonary symptoms.¹⁰ Complications at operation for Zenker diverticulum may first be related to poor exposure. We prefer an incision along the anterior border of the sternocleidomastoid muscle, which allows wide exposure of the pharyngoesophageal junction. Small oblique incisions along the skin lines are limiting. These incisions were used in all the patients presenting with an incomplete myotomy that had failed to improve the oropharyngeal dysphagia.¹¹ Sacrifice of the superficial branch of the cervical cutaneous nerve results in hypoesthesia and paresthesia of the ipsilateral submandibular area. This may subside over time.

The diverticulum, if large, is usually visualized under the buccopharyngeal fascia, the fibroareolar tissue covering the posterior pharyngoesophageal junction. As the majority of the diverticula seen today are smaller than 3 cm, they can be easily missed if this fascia is not opened, allowing protrusion of the diverticulum. Once exposed, its tip is seized with a small Duval clamp and lifted to allow the safe insertion of an intraesophageal bougie. This bougie serves as a stent to support the myotomy, while also protecting the esophageal lumen integrity. As diverticulectomy alone for a Zenker has been reported to result in a high recurrence rate over time, a myotomy or myectomy of the pharyngoesophageal junction is considered the essential part of the treatment whereas diverticulectomy or diverticulum suspension is seen as treatment for the complication of the dysfunction.

Mucosal perforation during the myotomy is usually recognized and repaired using small resorbable sutures. When the diverticulum is resected, the endoluminal bougie is there to prevent narrowing of the esophageal lumen during the resection. The resection line is usually made transverse. When the diverticulum is suspended, its tip is usually tied to the transected muscle margin of the hypopharynx. Fixation to the prevertebral fascia has been seen to cause fasciitis and osteomyelitis as the sutures made through the tip of the diverticulum are considered contaminated. To be complete, a cricopharyngeal myotomy must include the fibers of the inferior constrictor of the pharynx, the cricopharyngeus, itself, and a small portion of the cervical esophagus musculature. The cut margins of the myotomy must allow outpouching of the mucosa over 50% of the circumference to avoid reclosure of the myotomy.

Postoperative complications may be significant. This is not only related to the technique, but also to age as a majority of those patients are elderly and frail. Wound infection and fistula formation are the most frequent complications seen. For a one-stage diverticulectomy, the reported infection rate was 3%, with half of these patients showing a fistula. In our own experience, with close to 100 patients, infection was the most frequent complication. The fistula rate was 1.5%. The Mayo Clinic experience suggests a recurrent nerve palsy in 3% of their 888 patients.¹² When reoperated, however, patients can expect the morbidity to increase to as high as 20%, explained by a more difficult mobilization of structures. When a fistula occurs, wide drainage of the wound is preferred as a first step. If there is no spontaneous early closure, a pedicled muscle flap of the sternocleidomastoid muscle is used to repair the fistula.

Recurrences were seen in 7% of Payne’s experience with 164 patients followed 5 to 14 years. Nicholson¹³ in a radiologic follow-up of 20 patients showed that 13 had a recurrent pouch. Hansen et al.¹⁴ saw recurrences in 3 of 19 patients, Bertelsen and Aasted¹⁵ in 14 of 68 cases, and Einarsson and Hallen¹⁶ in 17 of 20 patients. Pouch formation probably develops over a significant period of time. This emphasizes that long-term radiologic documentation is necessary if objective results are to be obtained. When only cricopharyngeal myotomy is offered to treat the diverticulum, less than satisfactory results are found in patients in whom a small but dependent pouch persists.

Endoscopic esophagodiverticulostomy had initially been popularized by Dohlman using coagulation and, later, using laser to create a single lumen between the diverticulum and the cervical esophagus.¹⁷ The use of surgical linear staplers has gained popularity in recent years. Initially proposed for high-risk patients, it has now been used in large reported series. Although clinical results seem less satisfactory, the complication rate is low. Decreased operating time and avoidance of recurrent nerve injury are often proposed as advantages. Chang et al.¹⁸ report a 2% complication rate without mortality. These include dental complications (7%), fever (4%), aspiration pneumonia (0.7%), and esophageal perforation (0.7%). Transient cord paralysis was seen in one patient. Case and Baron¹⁹ reported minor bleeding in 23%, perforation in 27%, and neck abscesses in 4.5% of treated patients.

Neurologic, Myogenic, and Idiopathic Dysphagia

Table 32-2 describes the morbidity and mortality resulting from cricopharyngeal myotomy for indications other than Zenker’s diverticulum. With proper selection, significant improvement in oropharyngeal dysphagia can be obtained.

Although in neurologic patients the dysphagia is usually related to poor coordination between swallowing, pharyngeal contraction, and upper sphincter relaxation, patients with muscular dysphagia have symptoms resulting from poor pharyngeal contraction and propulsion with incomplete sphincter opening. Adequate symptom documentation and quantification with videoradiologic assessment are essential for appropriate patient selection. Complications related to the myotomy in these patients are less frequent than in Zenker’s patients. Mucosal penetration, although frequent, is rarely followed by infection or fistula formation. Campbell et al.,²⁰ however, report pharyngeal leaks in 8% of their patients. In our experience, primary repair with resorbable sutures or a pedicled muscle flap is usually satisfactory to prevent this complication. Persistent aspiration with pulmonary complications may have to be approached by a permanent tracheostomy with laryngeal diversion or resection. Mortality was seen mostly in the muscular dysphagia group (4%) and is always secondary to severe lung infection.

Operations on the Esophageal Body and the Lower Esophageal Sphincter

Achalasia

Achalasia is the most frequent and best described esophageal motor dysfunction. The diagnostic criteria are well established and recently three types of the same abnormalities were proposed to classify these dysfunctions.²¹ A wrong diagnosis remains a possibility as a number of medical conditions can mimic this primary disorder clinically, radiologically, and manometrically. Pseudoachalasia by an obstructive subcardial lesion must especially be ruled out before reaching the diagnosis. A comprehensive approach to investigation is essential to allow an objective diagnosis in all patients and prevent misdirected therapy.

Preoperative Complications They are related primarily to the consequences of esophageal retention/obstruction. Aspiration pneumonia was reported in 10% of patients by Ellis and Olsen²² and Clouse and Lustman,²³ whereas Effler et al.²⁴ observed nocturnal aspiration in 24% of their patients and Black et al.²⁵ in 46%. Olsen²⁶ reported a 10% incidence of pulmonary infection in their series, including a chronic form of mycobacterial infection suspected to be caused by the fatty supernatant found frequently in the achalasic esophagus. Acute airway obstruction may require rapid intubation. This is seen mostly with end-stage achalasia. One of the dreaded complications is massive aspiration during the induction of anesthesia. Allen and Clagett reported that one of the two deaths in their series resulted from that complication.²⁷ Whenever an esophagus is dilated with documented retention, a safe approach remains a liquid diet for the days preceding the operation, emptying and lavage of the esophagus the morning of the operation, and awake intubation by the anesthetist before the induction of anesthesia.

Intraoperative Complications These are related to the technique and to the type of approach selected. Even to this day there is no consensus on what an ideal myotomy for achalasia should be. The modified Heller myotomy in use today varies significantly in length on the esophagus and in its extension on the gastric wall. Independent of the surgical approach selected, the principles for treatment should be identical: remove the obstructive effect of the lower esophageal sphincter. The ­overall mortality reported varies between 0.7% and 2.8% with smaller series showing a higher mortality.²⁸ Mucosal perforations during the myotomy are usually inadvertent and immediately repaired using resorbable sutures. Andreollo and Earlam²⁹ documented mucosal penetration in 1.1% of their review of over 5000 myotomies. This led to a fistula and empyema in 0.4% of all patients. Moreno González et al.³⁰ found a similar prevalence in their European study. In most large series, the morbidity is related to mucosal penetration. Ellis³¹ reported it in 25 of their 262 patients whereas Okike et al.³² observed leaks and sepsis in 1% of their 468 patients. Repeat myotomies are at higher risk of mucosal damage.^33–35 Little et al.³⁶ proposed a posterior myotomy in this situation to improve the safety of the operation. Mortality in surgery for achalasia is usually the immediate consequence of fistula formation and sepsis. In view of the severity of this technical mishap, added protection after the repair is indicated with the use of a partial fundoplication, or pleural or muscular flap, depending on the level of the mucosal damage in the myotomized area.

Persistent dysphagia immediately after the operation usually results from an incomplete myotomy.³⁷ Reoperation gives satisfactory results in 75% of the group.

Paraesophageal hernias are usually the result of a disrupted hiatus after the operation. This complication has been reported frequently in open surgery series.^38–41 Immediate reoperation is indicated to prevent complications on the herniated stomach or on the mucosa denuded of its muscularis. Anatomic restoration of the hiatus with a partial Belsey-type fundoplication should allow a proper seal of the abdominal cavity from the chest.

Late Complications Complications can result from altering the function of the lower esophageal sphincter;^38–41 or when esophageal body dysfunction is not modified by the operation and aperistalsis persists; an insufficient myotomy fails to relieve dysphagia; or adequate sphincter division exposes to the possibility of reflux disease.

When dysphagia recurs 6 months to 1 year after the operation, this usually suggests healing of the myotomy.^31,42 The absence of esophagitis at endoscopy with a competent lower esophageal sphincter on manometry and at endoscopy suggests either rehealing or an incomplete myotomy. Difficulty in identifying the myotomy zone at the operation usually confirms that impression. Periesophageal sclerosis with hyalinization also has been reported by Fekete and Lortat-Jacob³⁷ and Peracchia et al.⁴³ Recurrent dysphagia is also seen with late-stage achalasia. Esophageal cancer must be ruled out.

Reflux esophagitis and stricture are the most frequent complications of the modified Heller myotomy. Extension of the myotomy on the gastric wall is considered important but if the myotomy extends more than 2 cm on the stomach, reflux disease will result in all patients.^44,45 Reflux disease increases with the passage of time: 24% at 1 year, 48% at 10 years, and stabilization at 52% after 13 years. At that time, 19% of patients present with a stricture. The more objective the evaluation, the higher the prevalence of reflux complications on the esophageal mucosa. Failed myotomies are predominantly caused by peptic esophagitis. Long-term reflux exposure may induce the appearance of columnar-lined metaplasia with its related morbidity. Ulcerations, fistulas, strictures, perforations, and malignant transformation may ensue if the condition goes untreated.