Central Surgical Association| Volume 82, ISSUE 4, P521-530, October 1977

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Management of complications of fundoplication and Barrett's esophagus

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      Two areas of esophageal surgery pose difficult and unsettled problems of management: reoperation for complications of fundoplication and the columnar-lined distal esophagus (Barrett's). Fifteen patients have required reoperation for gastric fistula (six), progressive esophagitis/stricture (four), obstruction by the wrap (three), carcinoma (one), failed pericardioesophagoplasty (one), and gastric ulcer (one). Of the six with gastric fistulas, five had had transthoracic Nissen procedures, and three died without surgical closure having been attempted. Three survived after operative closure (one) and esophageal exclusion (two). Progressive esophagitis/stricture occurred following abdominal Nissen operations (two), Belsey procedure (one), and Belsey with Collis gastroplasty (one). Remedial thoracic Nissen operations gave good results in two patients. Esophageal obstruction by the wrap (three) was managed by resection and distal colon interposition with good results in each patient. Those with cancer, a failed pericardioesophagoplasty, and gastric ulcer were managed by esophagogastrectomy, Woodward procedure, and wedge resection, respectively. All are doing well. Eight patients had Barrett's esophagus, one with an associated cancer (13%). Fundoplication has given good results in three of five patients, and there was one death from gastric fistula. Two are awaiting operation. Failed operations on the gastroesophageal junction can be remedied by carefully selected surgical techniques based on a thorough preoperative evaluation of the patient. Barrett's esophagus is managed successfully with fundoplication and dilatation. There is an increased incidence of cancer in this disorder, which demands long-term follow-up.
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