Laparoscopic Redo Surgery in the Gastroesophageal Junction Area

Abstract

Background: Laparoscopy has become the standard surgical approach in cases of gastroesophageal rei¬‚ux disease, large paraesophageal hiatal hernia and achalasia, with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. After laparoscopic Heller myotomy some patients still have symptoms and require reoperation. Laparoscopic redo surgery (LRS) for GERD, hiatal hernia or achalasia is still technically challenging and its outcome has not been reported in the country. We report the surgical technique and initial results of LRS for recurrent GERD, hiatal hernia and achalasia.Materials and Methods: Between January, 2006 and January, 2016, 23 redo laparoscopic operations were attempted, 2 for the third time. Indications were: large symptomatic hiatal hernia - 2, hiatal hernia with reflux - 9, hiatal hernia with reflux and dysphagia - 7, hiatal hernia with dysphagia - 3, one patient was reoperated for acute hiatal reherniation and one - for recurrent achalasia.Results: The patients consisted of 15 men and 8 women with a mean age of 59 (range 38-79). The types of primary operations were 19 Nissen, 2 Hill and 1 anterior Fundoplications, and 1 Heller-Dor procedure. In 3 cases meshes were used. The average interval from the primary surgery was 26.5 (range 1-120) months. Laparoscopic surgery was performed on 22 patients and one conversion occured. Fundoplication was left in place in 5 patients. It was redone in 12 (2 were slipped) and five patients were converted from Nissen to Toupet fundoplication since floppy. Nissen could not be performed properly because of thickened gastric fundus. Cruroplasty was performed in all of the cases. One patient required a 3rd operation for recurrence after redo fundoplication. The operation time was 230±65min. (70 - 300 min.) Soft diet started on the first POD and the post-operative stay was 3.7 days. Intraoperative complications occurred in 17.4 % of patients (gastric perforation - 2, esophageal perforation - 1, pneumothorax requiring chest tubes: 1. One patient died on POD 2. With a median follow-up period of 42 months, 22 patients have been without recurrence and 1 patient was reoperated.Conclusion: Laparoscopic redo surgery for recurrent GERD, hiatal hernia or achalasia is feasible and effective and can be attempted in all cases.