•
An Evaluation of the Nissen Fundoplication 1
•
Diagnostic Radiology
Jovitas Skueas, M.D., Jagdlsh C. Mangla, M.D., F.R.C.P.(C), F.A.C.P., James T. Adams, M.D., and William Cute"", M.D. The characteristic radiological findings which follow a Nissen fundoplication are reviewed. The esophagus may be narrowed but is intrinsically normal. A pseudotumor at the medial aspect of the fundus is generally present. The history and radiographic findings can normally differentiate this defect from neoplasm or a nonoperated hiatal hernia. Postoperative clinical evaluation has shown this procedure to be very valuable in the amelioration of symptoms. INDEX TERMS: Esophagus, obstruction. Esophagus, surgery. Fundoplication • Hernia, diaphragmatic • Stomach, cardioesophageal junction Radiology 118:539-543, March 1976
•
• T is generally believed that
successful treatment of gastroesophageal reflux is based more on correction of the underlying physiologic factors rather than correction of any specific anatomic abnormality. Importance has been placed on achieving competence of the cardia although there is no agreement on the primary factors responsible for maintaining competence. The lack of uniform success has been attested by the many surgical procedures developed which are designed to prevent reflux of gastric contents into the lower esophagus. Fundoplication was first reported by Nissen in 1956 (8) and with the passage of time this procedure has continued to gain greater acceptance. An abdominal approach is generally used. The distal esophagus is mobilized and the upper portion of the stomach freed of all attachments by dividing the upper portion of the gastrohepatic ligament and the short gastric arteries. The redundant gastric fundus is then wrapped around both sides of the esophagus and sutured together anteriorly about 4-6 cm (Fig. 1). As a result of this surgical technique, two means of avoiding gastroesophageal reflux are achieved. First, the fundus forms a cuff around a relatively long and narrowed segment of the distal esophagus. Second, there is restoration of an acute angle of His. In order to avoid excessive narrowing of the esophagus, the plication procedure is performed around a large-bore nasogastric tube within the esophagus. When there is a coexisting hiatal hernia, most surgeons recommend simultaneous repair by approximating the crural limbs of the hiatus behind the esophagus, thus fixing the gastroesophageal junction below the diaphragm. A transthoracic approach is used when a short esophagus is suspected clinically, or when it is believed that there may be extensive adhesions in the gastroesophageal region. A short esophagus is usually the result of prolonged esophagitis with eventual fibrosis; rarely is it congenital in nature. Even if the distal esophagus cannot be brought down into the abdomen, the gastric fundus can be wrapped around the esophagus and left in an intrathoracic position. Vagotomy and a
I
Fig. 1. Technique of fundoplication. The abdominal esophagus is mobilized and the upper portions of the lesser and greater curvatures of the stomach freed of all attachments. If an esophageal hiatus hernia is present, it is reduced and the hiatus closed posteriorly. The redundant fundus is then wrapped around the distal esophagus and sutured together anteriorly tor a distance of about 5 cm. Heavy nonabsorbable suture material is used and each suture includes a bite of the esophageal wall. The plication is carried out with a #36 or #38 Ewald tube within the esophagus to prevent excessive narrowing of the lumen.
gastric drainage operation are often added if the patient has co-existent peptic ulcer disease. Thus the radiological changes may be somewhat variable and may be seen either in the abdomen or in the thorax. Several somewhat atypical patients illustrate the broad spectrum of findings encountered. CASE REPORTS CASE I. A 59-year-old obese edentulous woman complained of substernal pain, dysphagia, nausea and vomiting. An upper gastrointestinal series revealed a gastric ulcer. Panendoscopy also showed esophagitis with esophageal erosions. She had been on anti-ulcer and anti-esophagitis medical therapy and had undergone surgery after showing no improvement. A vagotomy, pyloroplasty and Nissen fundoplication were performed. Her postoperative course was uncomplicated and she was swallowing normally. About 10 days after discharge, she swallowed several chicken gizzards and shortly after
1 From the Departments of Radiology (J. S., W. C.), Medicine (J. C. M.) and Surgery (J. T. A.), University of Rochester Medical Center, Rochester, N.Y. Revised manuscript accepted for publication in October 1975. shan
539
540
JOVIT AS SKUCAS AND OTHERS
March 1976
the esophagus. A Nissen fundoplication was performed. Currently, three years after surgery, he remains asymptomatic, still has esophageal speech, and recent biopsies still reveal gastric mucosa in the lower two thirds of the esophagus. DISCUSSION
Fig. 2. Emergency esophagram after an episode of acute dysphagia 10 days after surgery. The nasogastric tube is filled with barium and outlines the esophageal lumen. Pieces of foreign matter (arrow) are present in the esophagus proximal to the obstruction. presented with acute dysphagia. An esophagram revealed a foreign body in the distal esophagus (Fig. 2) which was removed through an endoscope using a snare forceps (7). The esophagram was repeated several days later, showing a typical configuration of a relatively recent Nissen fundoplication (Fig. 3). CASE II. A 52-year-old man had had numerous episodes of hematemesis for seven years. The source of bleeding was thought to be a duodenal ulcer seen on a prior upper gastrointestinal examination. He also had experienced episodic burning pain in the epigastrium and substernal region with deep penetrating radiation to the back. An esophagram revealed a hiatal hernia and an ulcer above the hernia. Endoscopy also showed the ulcer and a markedly red, edematous and friable lower portion of the esophagus. He underwent vagotomy, pyloroplasty and Nissen fundoplication after resection of the esophageal ulcer (Fig. 4). Endoscopy two months after surgery showed marked improvement. He is now completely asymptomatic. CASE III. A 51-year-old man had continued epigastric pain, heartburn and dysphagia of 18 months' duration although he was on medical therapy. A laryngectomy had been performed for cancer of the larynx and he could phonate only through the esophageal speech mechanism. He had one episode of hematemesis and required five units of blood; an upper gastrointestinal examination at that time demonstrated a hiatus hernia and reflux into the esophagus. Initial gastroscopy was unrewarding. Esophagoscopy several months later showed an esophageal ulcer 7 mm in diameter at the level of the aortic arch with the surrounding area being covered by a necrotic pseudomembrane. Serial biopsies of the esophagus revealed that the mucosa distal to the ulcer was gastric in nature (Barrett's esophagus) and extended from the ulcer to the distal end of
The major indication for fundoplication is significant symptomatic reflux of gastric secretions into the esophagus. Unfortunately, the severity of a patient's pain may not be related to the degree of esophagitis present. Hematemesis may be the initial clue to an underlying esophagitis and hiatus hernia, although chronic gastrointestinal bleeding is the more common presentation. The initial investigation should include an esophagram, upper gastrointestinal series, and esophagoscopy. It is not unusual to see minor radiological changes in the esophagus in the face of severe erosions and inflammation. Gastric or duodenal ulcers may co-exist. A hiatus hernia or reflux may not be demonstrable radiologically at the time of the examination; these negative findings are of limited value with a typical history of reflux esophagitis. Similarly, even with clearly demonstrated hiatus hernia, the patient's presenting symptoms may be ,due to a peptic ulcer, hepatobiliary disease, pancreatitis, or even cardiac disease. The association of cholelithiasis and hiatus hernia is well known. Patients who fail to respond to a trial of good medical therapy are selected for fundoplication. If the inflammation is of relatively long duration, the resultant esophageal stenosis may force the patient to seek medical attention due to dysphagia with solid foods. Some of the other indications for fundoplication include achalasia, scleroderma, or any other related condition producing reflux esophagitis not responding to medical therapy. Initial baseline radiological examinations should be obtained shortly after surgery. The radiographic findings after a Nissen fundoplication are usually rather characteristic (1, 12). There is a prominent filling defect at the gastroesophageal junction. It is generally smoothly outlined and symmetrical on both sides of the distal esophagus (Fig. 3, A). However, if this part of the stomach has been incompletely filled with barium or air, an irregular outline may be present (Fig. 5). The usual appearance when distended is that of the distal esophagus passing through a "tunnel" with a concave mass impression on the stomach at this site (Fig. 3, B). If the study is done immediately after surgery, the resultant edema surrounding this area may make the mass rather prominent. Subsequent follow-up studies show the mass gradually subsiding over a period of weeks to its final form (Fig. 6). Occasionally, as the edema clears, the pseudotumor may regress sufficiently so that longtime follow-up radiographic studies barely demonstrate an abnormality (Fig. 7). The pseudotumor is generally present to a varying degree and can be confused with neoplasm in this area unless the patient's prior history is known. Ettinger et al. described a pseudotumor in 33 of 34 patients (3).
Vol. 118
AN EVALUATION OF THE NISSEN FUNDOPLICATION
541
Diagnostic Radiology
Fig. 3. Typical appearance 13 days after Nissen fundoplication. A vagotomy had also been performed. A. Air view outlining symmetrical fundal defect. S. Barium-filled view, with the distal esophagus passing through a "tunnel."
Actually, the differentiation of a fundoplication pseudotumor from a neoplasm in this area is not very difficult if one considers that the esophageal lumen in the pseudotumor region is well preserved, the gastroesophageal junction can be well delineated, and there is no
distortion of the barium column in the esophagus. However, after fundoplication there is distortion of the medial aspect of the gastric fundus. That portion of the fundus which has been wrapped around the esophagus may show either barium or air extending in a semilunar
Fig. 4. Postoperative (5 days) esophagram outlining the pseudotumor defect in the fundus. A hiatus hernia is still present (arrows) but there was no reflux and the distal portion of the hernia has a narrowed appearance. Fig. 5. Irregular outline at the gastroesophageal region seven days after Nissen fundoplication. Fig. 6. Esophagram two years after Nissen fundoplication. A relatively small residual defect is present.
542
JOVITAS SKUCAS AND OTHERS
March 1976
Fig. 7. A. Postoperative (2 weeks) esophagram reveals a relatively large pseudotumor. B. Esophagram four months later shows considerably less distortion but a small defect is still present.
fashion to a varying degree. Metal clips may be present in the area (Fig. 8). Generally, no reflux can be elicited after fundoplication, even after the appropriate provocative radiological maneuvers and even if there is recurrence of a hiatus hernia (9). A moon-shaped fundal defect may be seen along the medial aspect of the fundus when an uncorrected hiatus hernia is present (5). This may simulate a small residual pseudotumor defect of fundoplication. Here, again, the patient's history of surgery leads one to the correct diagnosis. The characteristic shape of the Nissen fundoplication differentiates it from the other hiatus hernia repair procedures. Possible confusion exists with the Belsey Mark IV fundoplication, wherein after reduction of the hernia the esophagus is sutured to the stomach and diaphragm (11). In both types of fundoplication a pseudotumor is produced, although in the Belsey Mark IV fundoplication there is somewhat sharper angulation of the lower esophagus. Some of the complications of fundoplication include iatrogenic perforation (9), separation of sutures with recurrence of reflux (9), abscess formation (1), fistulae (1, 6) including a gastropericardial fistula (4), and postoperative stenosis (6). Stenosis can be minimized by using a large-bore Ewald tube as a guide in the esophagus. The complications may be readily apparent during appropriate radiological examination. Esophageal obstruction due to food just proximal to the stenotic site may occur (Fig. 2). We have seen a pa-
tient with a gastropleural fistula. However, complications are relatively infrequent and the success rate is high. One of our patients continuously suffered dysphagia after fundoplication (Fig. 7). Surgery revealed a hiatal hernia with pronounced esophagitis. She was also believed to have achalasia. It is of interest that during the examination performed four months after surgery, her symptoms were most pronounced during intermittent episodes of marked tertiary contractions in the esophagus proximal to the segment involved by surgery. A patient may complain of a feeling of fullness in the epigastric region. In spite of the relatively fixed and narrowed distal esophagus, most of our patients were able to vomit. In one series of 58 patients, only 2 complained of inability to vomit (10). Ten of the 58 patients complained of inability to belch. However, the gas-bloating syndrome apparently is rare; Ellis et al. reported only one patient with this complaint in their series of 27 (2). Sphincteric pressure increases after fundoplication and there is also an increase in the length of the high pressure zone (2). Both of these factors may contribute to the encouraging results obtained with the Nissen fundoplication. CONCLUSION
The radiological changes after Nissen fundoplication are characteristic. The esophageal lumen is intact, with the fundoplication defect encircling the esophagus. The changes gradually regress to an eventual small mass at
Vol. 118
AN EVALUATION OF THE NISSEN FUNDOPLICATION
543
Diagnostic Radiology
the gastroesophageal region. An initial postoperative esophagram is very helpful in evaluating this region and gives the radiologist a baseline for possible future change due to unrelated disease processes. Department of Radiology School of Medicine University of Rochester Rochester, N. Y. 14642
REFERENCES 1. Cohen WN: The fundoplication repair of sliding esophageal hiatus hernia: its roentgenographic appearance. Am J Roentgenol 104:625-631, Nov 1968 2. Ellis FH, Garabedian M, Gibb SP: Fundoplication for gastroesophageal reflux. Arch Surg 107:186-192, Aug 1973 3. Ettinger A, Paul RE Jr, Moran JM: Gastric pseudotumor after fundoplication. Gastroenterology 61:299-304, Sep 1971 4. Ikard RW, Jacobs JK: Gastropericardial fistula and pericardial abscess: unusual complications of subphrenic abscess following Nissen fundoplication. Southern Mad J 67:17-19, Jan 1974 5. Kalokerinos J: The moon-shaped fundal defect of hiatus hernia: a new radiological sign. Aust RadioI13:96-102, Feb 1969 6. Krupp S, Rossetti M: Surgical treatment of hiatal hernias by fundoplication and gastropexy (Nissen repair). Ann Surg 164: 927-934, Nov 1966 7. Mangla JC, Desbaillets LG: Endoscopic removal of chicken gizzards by polypectomy snare in a patient with Nissen's fundoplication. Am J Gastroenterol 64:133-136, Aug 1975 8. Nissen R: Eine elnfache Operation zur Beeinflussung der Refluxoesophagitis. Schweiz Med Wochnschr 86:590-592, 18 May 1956 9. Nissen R: Gastropexy and "fundoplication" in surgical treatment of hiatal hernia. Am J Dig Dis 6:954-961, Oct 1961 10. Safaie-Shirazi S, Zike WL, Anuras S, et al: Nissen fundoplication without crural repair. Arch Surg 108:424-427, Apr 1974
Fig. 8. One year after Nissen fundoplication there is a prominent mass "simulating" a tumor. Applying the radiological Criteria outlined in the text allows differentiation from a neoplasm.
11. Skinner DB, Belsey RHR: Surgical management of esophageal reflux and hiatus hernia: long-term results with 1,030 patients. J Thorac Cardiovasc Surg 53:33-54, Jan 1967 12. Teixidor HS, Evans JA: Roentgenographic appearance of the distal esophagus and the stomach after hiatal hernia repair. Am J RoentgenoI119:245-258, Oct 1973
An Evaluation of the Nissen Fundoplication 1
•
Diagnostic Radiology
Jovitas Skueas, M.D., Jagdlsh C. Mangla, M.D., F.R.C.P.(C), F.A.C.P., James T. Adams, M.D., and William Cute"", M.D. The characteristic radiological findings which follow a Nissen fundoplication are reviewed. The esophagus may be narrowed but is intrinsically normal. A pseudotumor at the medial aspect of the fundus is generally present. The history and radiographic findings can normally differentiate this defect from neoplasm or a nonoperated hiatal hernia. Postoperative clinical evaluation has shown this procedure to be very valuable in the amelioration of symptoms. INDEX TERMS: Esophagus, obstruction. Esophagus, surgery. Fundoplication • Hernia, diaphragmatic • Stomach, cardioesophageal junction Radiology 118:539-543, March 1976
•
• T is generally believed that
successful treatment of gastroesophageal reflux is based more on correction of the underlying physiologic factors rather than correction of any specific anatomic abnormality. Importance has been placed on achieving competence of the cardia although there is no agreement on the primary factors responsible for maintaining competence. The lack of uniform success has been attested by the many surgical procedures developed which are designed to prevent reflux of gastric contents into the lower esophagus. Fundoplication was first reported by Nissen in 1956 (8) and with the passage of time this procedure has continued to gain greater acceptance. An abdominal approach is generally used. The distal esophagus is mobilized and the upper portion of the stomach freed of all attachments by dividing the upper portion of the gastrohepatic ligament and the short gastric arteries. The redundant gastric fundus is then wrapped around both sides of the esophagus and sutured together anteriorly about 4-6 cm (Fig. 1). As a result of this surgical technique, two means of avoiding gastroesophageal reflux are achieved. First, the fundus forms a cuff around a relatively long and narrowed segment of the distal esophagus. Second, there is restoration of an acute angle of His. In order to avoid excessive narrowing of the esophagus, the plication procedure is performed around a large-bore nasogastric tube within the esophagus. When there is a coexisting hiatal hernia, most surgeons recommend simultaneous repair by approximating the crural limbs of the hiatus behind the esophagus, thus fixing the gastroesophageal junction below the diaphragm. A transthoracic approach is used when a short esophagus is suspected clinically, or when it is believed that there may be extensive adhesions in the gastroesophageal region. A short esophagus is usually the result of prolonged esophagitis with eventual fibrosis; rarely is it congenital in nature. Even if the distal esophagus cannot be brought down into the abdomen, the gastric fundus can be wrapped around the esophagus and left in an intrathoracic position. Vagotomy and a
I
Fig. 1. Technique of fundoplication. The abdominal esophagus is mobilized and the upper portions of the lesser and greater curvatures of the stomach freed of all attachments. If an esophageal hiatus hernia is present, it is reduced and the hiatus closed posteriorly. The redundant fundus is then wrapped around the distal esophagus and sutured together anteriorly tor a distance of about 5 cm. Heavy nonabsorbable suture material is used and each suture includes a bite of the esophageal wall. The plication is carried out with a #36 or #38 Ewald tube within the esophagus to prevent excessive narrowing of the lumen.
gastric drainage operation are often added if the patient has co-existent peptic ulcer disease. Thus the radiological changes may be somewhat variable and may be seen either in the abdomen or in the thorax. Several somewhat atypical patients illustrate the broad spectrum of findings encountered. CASE REPORTS CASE I. A 59-year-old obese edentulous woman complained of substernal pain, dysphagia, nausea and vomiting. An upper gastrointestinal series revealed a gastric ulcer. Panendoscopy also showed esophagitis with esophageal erosions. She had been on anti-ulcer and anti-esophagitis medical therapy and had undergone surgery after showing no improvement. A vagotomy, pyloroplasty and Nissen fundoplication were performed. Her postoperative course was uncomplicated and she was swallowing normally. About 10 days after discharge, she swallowed several chicken gizzards and shortly after
1 From the Departments of Radiology (J. S., W. C.), Medicine (J. C. M.) and Surgery (J. T. A.), University of Rochester Medical Center, Rochester, N.Y. Revised manuscript accepted for publication in October 1975. shan
539
540
JOVIT AS SKUCAS AND OTHERS
March 1976
the esophagus. A Nissen fundoplication was performed. Currently, three years after surgery, he remains asymptomatic, still has esophageal speech, and recent biopsies still reveal gastric mucosa in the lower two thirds of the esophagus. DISCUSSION
Fig. 2. Emergency esophagram after an episode of acute dysphagia 10 days after surgery. The nasogastric tube is filled with barium and outlines the esophageal lumen. Pieces of foreign matter (arrow) are present in the esophagus proximal to the obstruction. presented with acute dysphagia. An esophagram revealed a foreign body in the distal esophagus (Fig. 2) which was removed through an endoscope using a snare forceps (7). The esophagram was repeated several days later, showing a typical configuration of a relatively recent Nissen fundoplication (Fig. 3). CASE II. A 52-year-old man had had numerous episodes of hematemesis for seven years. The source of bleeding was thought to be a duodenal ulcer seen on a prior upper gastrointestinal examination. He also had experienced episodic burning pain in the epigastrium and substernal region with deep penetrating radiation to the back. An esophagram revealed a hiatal hernia and an ulcer above the hernia. Endoscopy also showed the ulcer and a markedly red, edematous and friable lower portion of the esophagus. He underwent vagotomy, pyloroplasty and Nissen fundoplication after resection of the esophageal ulcer (Fig. 4). Endoscopy two months after surgery showed marked improvement. He is now completely asymptomatic. CASE III. A 51-year-old man had continued epigastric pain, heartburn and dysphagia of 18 months' duration although he was on medical therapy. A laryngectomy had been performed for cancer of the larynx and he could phonate only through the esophageal speech mechanism. He had one episode of hematemesis and required five units of blood; an upper gastrointestinal examination at that time demonstrated a hiatus hernia and reflux into the esophagus. Initial gastroscopy was unrewarding. Esophagoscopy several months later showed an esophageal ulcer 7 mm in diameter at the level of the aortic arch with the surrounding area being covered by a necrotic pseudomembrane. Serial biopsies of the esophagus revealed that the mucosa distal to the ulcer was gastric in nature (Barrett's esophagus) and extended from the ulcer to the distal end of
The major indication for fundoplication is significant symptomatic reflux of gastric secretions into the esophagus. Unfortunately, the severity of a patient's pain may not be related to the degree of esophagitis present. Hematemesis may be the initial clue to an underlying esophagitis and hiatus hernia, although chronic gastrointestinal bleeding is the more common presentation. The initial investigation should include an esophagram, upper gastrointestinal series, and esophagoscopy. It is not unusual to see minor radiological changes in the esophagus in the face of severe erosions and inflammation. Gastric or duodenal ulcers may co-exist. A hiatus hernia or reflux may not be demonstrable radiologically at the time of the examination; these negative findings are of limited value with a typical history of reflux esophagitis. Similarly, even with clearly demonstrated hiatus hernia, the patient's presenting symptoms may be ,due to a peptic ulcer, hepatobiliary disease, pancreatitis, or even cardiac disease. The association of cholelithiasis and hiatus hernia is well known. Patients who fail to respond to a trial of good medical therapy are selected for fundoplication. If the inflammation is of relatively long duration, the resultant esophageal stenosis may force the patient to seek medical attention due to dysphagia with solid foods. Some of the other indications for fundoplication include achalasia, scleroderma, or any other related condition producing reflux esophagitis not responding to medical therapy. Initial baseline radiological examinations should be obtained shortly after surgery. The radiographic findings after a Nissen fundoplication are usually rather characteristic (1, 12). There is a prominent filling defect at the gastroesophageal junction. It is generally smoothly outlined and symmetrical on both sides of the distal esophagus (Fig. 3, A). However, if this part of the stomach has been incompletely filled with barium or air, an irregular outline may be present (Fig. 5). The usual appearance when distended is that of the distal esophagus passing through a "tunnel" with a concave mass impression on the stomach at this site (Fig. 3, B). If the study is done immediately after surgery, the resultant edema surrounding this area may make the mass rather prominent. Subsequent follow-up studies show the mass gradually subsiding over a period of weeks to its final form (Fig. 6). Occasionally, as the edema clears, the pseudotumor may regress sufficiently so that longtime follow-up radiographic studies barely demonstrate an abnormality (Fig. 7). The pseudotumor is generally present to a varying degree and can be confused with neoplasm in this area unless the patient's prior history is known. Ettinger et al. described a pseudotumor in 33 of 34 patients (3).
Vol. 118
AN EVALUATION OF THE NISSEN FUNDOPLICATION
541
Diagnostic Radiology
Fig. 3. Typical appearance 13 days after Nissen fundoplication. A vagotomy had also been performed. A. Air view outlining symmetrical fundal defect. S. Barium-filled view, with the distal esophagus passing through a "tunnel."
Actually, the differentiation of a fundoplication pseudotumor from a neoplasm in this area is not very difficult if one considers that the esophageal lumen in the pseudotumor region is well preserved, the gastroesophageal junction can be well delineated, and there is no
distortion of the barium column in the esophagus. However, after fundoplication there is distortion of the medial aspect of the gastric fundus. That portion of the fundus which has been wrapped around the esophagus may show either barium or air extending in a semilunar
Fig. 4. Postoperative (5 days) esophagram outlining the pseudotumor defect in the fundus. A hiatus hernia is still present (arrows) but there was no reflux and the distal portion of the hernia has a narrowed appearance. Fig. 5. Irregular outline at the gastroesophageal region seven days after Nissen fundoplication. Fig. 6. Esophagram two years after Nissen fundoplication. A relatively small residual defect is present.
542
JOVITAS SKUCAS AND OTHERS
March 1976
Fig. 7. A. Postoperative (2 weeks) esophagram reveals a relatively large pseudotumor. B. Esophagram four months later shows considerably less distortion but a small defect is still present.
fashion to a varying degree. Metal clips may be present in the area (Fig. 8). Generally, no reflux can be elicited after fundoplication, even after the appropriate provocative radiological maneuvers and even if there is recurrence of a hiatus hernia (9). A moon-shaped fundal defect may be seen along the medial aspect of the fundus when an uncorrected hiatus hernia is present (5). This may simulate a small residual pseudotumor defect of fundoplication. Here, again, the patient's history of surgery leads one to the correct diagnosis. The characteristic shape of the Nissen fundoplication differentiates it from the other hiatus hernia repair procedures. Possible confusion exists with the Belsey Mark IV fundoplication, wherein after reduction of the hernia the esophagus is sutured to the stomach and diaphragm (11). In both types of fundoplication a pseudotumor is produced, although in the Belsey Mark IV fundoplication there is somewhat sharper angulation of the lower esophagus. Some of the complications of fundoplication include iatrogenic perforation (9), separation of sutures with recurrence of reflux (9), abscess formation (1), fistulae (1, 6) including a gastropericardial fistula (4), and postoperative stenosis (6). Stenosis can be minimized by using a large-bore Ewald tube as a guide in the esophagus. The complications may be readily apparent during appropriate radiological examination. Esophageal obstruction due to food just proximal to the stenotic site may occur (Fig. 2). We have seen a pa-
tient with a gastropleural fistula. However, complications are relatively infrequent and the success rate is high. One of our patients continuously suffered dysphagia after fundoplication (Fig. 7). Surgery revealed a hiatal hernia with pronounced esophagitis. She was also believed to have achalasia. It is of interest that during the examination performed four months after surgery, her symptoms were most pronounced during intermittent episodes of marked tertiary contractions in the esophagus proximal to the segment involved by surgery. A patient may complain of a feeling of fullness in the epigastric region. In spite of the relatively fixed and narrowed distal esophagus, most of our patients were able to vomit. In one series of 58 patients, only 2 complained of inability to vomit (10). Ten of the 58 patients complained of inability to belch. However, the gas-bloating syndrome apparently is rare; Ellis et al. reported only one patient with this complaint in their series of 27 (2). Sphincteric pressure increases after fundoplication and there is also an increase in the length of the high pressure zone (2). Both of these factors may contribute to the encouraging results obtained with the Nissen fundoplication. CONCLUSION
The radiological changes after Nissen fundoplication are characteristic. The esophageal lumen is intact, with the fundoplication defect encircling the esophagus. The changes gradually regress to an eventual small mass at
Vol. 118
AN EVALUATION OF THE NISSEN FUNDOPLICATION
543
Diagnostic Radiology
the gastroesophageal region. An initial postoperative esophagram is very helpful in evaluating this region and gives the radiologist a baseline for possible future change due to unrelated disease processes. Department of Radiology School of Medicine University of Rochester Rochester, N. Y. 14642
REFERENCES 1. Cohen WN: The fundoplication repair of sliding esophageal hiatus hernia: its roentgenographic appearance. Am J Roentgenol 104:625-631, Nov 1968 2. Ellis FH, Garabedian M, Gibb SP: Fundoplication for gastroesophageal reflux. Arch Surg 107:186-192, Aug 1973 3. Ettinger A, Paul RE Jr, Moran JM: Gastric pseudotumor after fundoplication. Gastroenterology 61:299-304, Sep 1971 4. Ikard RW, Jacobs JK: Gastropericardial fistula and pericardial abscess: unusual complications of subphrenic abscess following Nissen fundoplication. Southern Mad J 67:17-19, Jan 1974 5. Kalokerinos J: The moon-shaped fundal defect of hiatus hernia: a new radiological sign. Aust RadioI13:96-102, Feb 1969 6. Krupp S, Rossetti M: Surgical treatment of hiatal hernias by fundoplication and gastropexy (Nissen repair). Ann Surg 164: 927-934, Nov 1966 7. Mangla JC, Desbaillets LG: Endoscopic removal of chicken gizzards by polypectomy snare in a patient with Nissen's fundoplication. Am J Gastroenterol 64:133-136, Aug 1975 8. Nissen R: Eine elnfache Operation zur Beeinflussung der Refluxoesophagitis. Schweiz Med Wochnschr 86:590-592, 18 May 1956 9. Nissen R: Gastropexy and "fundoplication" in surgical treatment of hiatal hernia. Am J Dig Dis 6:954-961, Oct 1961 10. Safaie-Shirazi S, Zike WL, Anuras S, et al: Nissen fundoplication without crural repair. Arch Surg 108:424-427, Apr 1974
Fig. 8. One year after Nissen fundoplication there is a prominent mass "simulating" a tumor. Applying the radiological Criteria outlined in the text allows differentiation from a neoplasm.
11. Skinner DB, Belsey RHR: Surgical management of esophageal reflux and hiatus hernia: long-term results with 1,030 patients. J Thorac Cardiovasc Surg 53:33-54, Jan 1967 12. Teixidor HS, Evans JA: Roentgenographic appearance of the distal esophagus and the stomach after hiatal hernia repair. Am J RoentgenoI119:245-258, Oct 1973
