Acute wrap migration after anti-reflux surgery: The devil is in the details

BACKGROUND: Laparoscopic anti-reflux surgery is a commonly performed surgery for gastro-oesophagal reflux disease and hiatus hernia. One of the life-threatening complications post fundoplication is acute migration of the wrap, into the mediastinum thus leading to ischaemia and gangrene of the herniated stomach, the time of presentation being within 7 days from index surgery. We present a series of 10 patients who had acute trans-diaphragmatic migration of wrap (in three patients with wrap disruption, there was migration of the entire stomach). PATIENTS AND METHODS: The study design is a retrospective study design. All 10 patients underwent laparoscopic management of their acute migration within 24 h of presentation following an urgent computed tomography scan to define the anatomy, the type of migration and vascularity of the stomach, as well as to rule out any concomitant collapse of the affected lung. The median age was 41 (38-70 years), and 7 were females and 3 males. All patients underwent reduction of herniated wrap, crural repair and seven patients underwent a posterior partial fundoplication, two patients underwent gastropexy and one patient had proximal gastric resection in view of non-viability of the proximal stomach in view of delayed diagnosis. RESULTS: Postoperatively, all patients (except one patient) were started on liquids followed by soft diet for a week. At a follow-up of 2 years, only two patients are on intermittent proton pump inhibitor use, the rest all others are free of any symptoms with no evidence of recurrence of hiatal hernias on follow-up imaging. CONCLUSION: Acute transdiaphragmatic wrap migration (<7 days from index surgery) requires a high index of suspicion with an emergent laparoscopic repair, to avoid life-threatening complications. The principles of surgery are to recognise the cause, restore the anatomy back to normal. A secure crural closure and a partial wrap with anchoring the wrap to the crura is equally important to avoid wrap migrations with gastropexy as a bailout choice. The key is to avoid postoperative retching and vomiting by suitable anaesthesia and antiemetics postoperatively. The use of indocyanine green dye can be helpful whenever vascularity is a concern. And lastly, tailored use of mesh along with PoRSHA can be used for reinforcement of crural closure when the crura are thin or when the inter-hiatal distance is >5 cms to avoid recurrences.