Herniation of an abdominal antireflux fundoplication into the chest: what does it mean?

作者：Deswysen Yannick; Volonte Francesco; Gutschow Christian; Romagnoli Renato; Strignano Paolo; Ouazzani Aous; Verstraete Luc; De Gheldere Charles; Thoma Maximillien; Uluma Vincent; Ungureanu Felicia; Mabrut Jean Yves; Collard Jean Marie^*

来源：European Journal of Cardio-Thoracic Surgery, 2014, 46(1): 121-126.

DOI：10.1093/ejcts/ezt553

• Reoperation of fundoplication
• Chest
• Oesophagus
• Gastroesophageal reflux disease
• Hiatal hernia

The specific contribution of the herniation of an abdominal antireflux fundoplication into the chest to symptomatic and therefore surgical failure remains unclear.
The study was conducted in 189 consecutive fundoplication patients, categorized as patients reoperated on for chest herniation of either an abdominal 360A degrees (Group 1; n = 95) or a partial (Group 2; n = 10) fundoplication, and patients having undergone an intrathoracic 360A degrees fundoplication for short oesophagus (Group 3; n = 84; reference group). There were four subgroups in Group 1: 1A: wrap still complete and perioesophageal; 1B: wrap still complete but perigastric; 1C: wrap still perioesophageal but partially disrupted and 1D: wrap perigastric and partially disrupted.
The prevalence of defective symptoms (heartburn and regurgitation) was significantly lower (P < 0.0001) in Group 3 (0.0%) and Subgroup 1A (3.7%) than in Subgroups 1B (84.4%), 1C (86.7%) and 1D (100%) and Group 2 (100%). The prevalence of obstructive symptoms (dysphagia, chest pain, necrosis and perforation) was significantly higher (P < 0.0001) in Subgroup 1A (100%) than in Subgroups 1B (57.8%), 1C (60.0%) and 1D (25.0%). The prevalence of a short oesophagus, an abdominal wall hernia repair and high abdominal pressure episodes in reoperated patients were 13.7, 36.2 and 67.2%, respectively.
Unlike perigastric or partial fundoplication, a 360A degrees perioesophageal abdominal fundoplication, when herniated into the chest, is still effective against reflux. Obstructive symptoms are due to either diaphragmatic strangulation or perigastric migration of the wrap (slipknot effect). Short oesophagus, weakness of the abdominal wall and high abdominal pressure episodes favour the herniation process.

• 出版日期2014-7