Obstructive complications of the Nissen fundoplication.

The obstructive complications of the Nissen fundoplication can be devastating. They are much more easily prevented than treated. The technical considerations in avoiding these complications are conceptually simple. The fundoplication should be done over a large intraesophageal stent. A no. 50 or 60 French dilator is appropriate and, in addition, the fundoplication should be left loose. If the fundoplication is to be left in the chest, the hiatus must be widely enlarged so that there is not the slightest hint of obstruction at the level of the diagphragm. Care must be taken in this case to approximate stomach to diaphragm. The Nissen fundoplication should be carried out using heavy sutures with generous bites of the stomach on both sides as well as bites of the esophageal wall and perhaps also the proximal stomach. If careful attention is paid to these technical details, the obstructive complications of the Nissen fundoplication should be eliminated.