Reoperative Antireflux Surgery Research Articles

The impact of obesity on gastroesophageal reflux disease recurrence following re-operative anti-reflux surgery.

Obese patients represent a large proportion of patients experiencing recurrent reflux and re-operations after initial anti-reflux surgery. However, there is a limited data describing the impact of obesity on GERD recurrence following re-operative procedures. A review of patients who underwent re-operative anti-reflux surgery (Re-ARS) between 2012 and 2023. Peri-operative characteristics and post-operative Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores were compared across the three BMI categories: (BMI < 25kg/m2, 25 ≤ BMI > 30kg/m2, and BMI ≥ 30kg/m2) over 12 IQR (9-14.9) months follow-up. Impedance planimetry measurements were included when it was utilized intraoperatively. Of 718 patients who underwent robotic ARS, 84 patients (11.6%) underwent Re-ARS, of which 29.7% had a BMI < 25kg/m2, 35.7% were ≤ 25 BMI < 30kg/m2, and 34.5% had a BMI ≥ 30kg/m2. The lower esophageal sphincter distensibility decreased similarly between groups with no differences in post-induction [3.2 ± 2 vs 4.5 ± 3.1 vs 3.9 ± 2.5 mm2/mmHg, p = 0.44] or post-fundoplication values [1 ± 0.6 vs 1.3 ± 0.7 vs 1.2 ± 0.6 mm2/mmHg, p = 0.46]. There was a significant improvement in GERD-HRQL scores postoperatively compared to preoperative levels across the three BMI classes (BMI < 25kg/m2: pre 17 IQR (12-22), post 7.5 (1.5-15), p = 0.04 vs ≤ 25 BMI < 30kg/m2: pre 26 IQR (10-34), post 8 IQR (0-17), p < 0.01 vs BMI ≥ 30kg/m2: pre 44 IQR (26-51), post 5 IQR (3.5-14.5), p < 0.001) during 12 IQR (9-14.9) months follow-up. The rates of hiatal hernia recurrence on barium swallow [5.2 vs 15.7 vs 13.7%, p = 0.32] during 7 IQR (5.2-9.2) months follow-up, and endoscopy [13.3 vs 16.6 vs 7.1%, p = 0.74] during 11.8 (IQR 5.6-17.1) months follow-up period were also similar between groups. GERD-HRQL scores in obese patients are expected to improve similarly compared to non-obese patients. Indicating that Re-ARS may be appropriate for patients across a range of BMIs.

Determination of causes of post-operative dysphagia after anti-reflux surgery based on intra-operative planimetry.

Dysphagia after anti-reflux surgery (ARS) is one of the most common indications for re-operative anti-reflux surgery and a leading cause of patient dissatisfaction. Unfortunately, the factors affecting its development are poorly understood. We investigated the correlation between pre-operative manometric and the intra-operative impedance planimetry (EndoFLIP™) measurements and development of post-operative dysphagia. A review of patients who underwent index robotic ARS in our institution. Patients who underwent pre-operative manometry and intra-operative EndoFLIP™ were included in our study. Dysphagia was assessed pre-operatively and at 3-month after surgery. Fifty-five patients (26.9%) reported post-operative dysphagia, and 34 (16.6%) reported new or worsening dysphagia. On pre-operative manometry, patients with post-operative dysphagia had a lower distal contractile integral [868.7 (IQR 402.2-1447) mmHg s cm vs 1207 (IQR 612.1-2111) mmHg s cm, p = 0.006) and lower esophageal sphincter (LES) pressure [14.7 IQR (8.9-23.6) mmHg vs 20.7 IQR (10.2-32.6) mmHg, p = 0.01] compared to those without post-operative dysphagia. They were also found to have higher pre-operative cross-sectional surface area (CSA) [83 IQR (44.5-112) mm2 vs 66 IQR (42-93) mm2, p = 0.02], and distensibility index (DI) [4.2 IQR (2.2-5.5) mm2/mmHg vs 2.9 IQR (1.6-4.6) mm2/mmHg, p = 0.003] compared to patients without post-operative dysphagia. Additionally, the decrease in CSA [-34 (-18.5, -74.5) mm2 vs -26.5 (-10.5, -53.7) mm2, p = 0.03] and DI [-2.3 (-1.2, -3.7) mm2/mmHg vs -1.6 (-0.7, -3.3) mm2/mmHg, p = 0.03] measurements were greater in patients with post-operative dysphagia. Patients who developed dysphagia post-operatively had poorer pre-operative motility and a greater change in LES characteristics intra-operatively. This finding suggests the utility of pre-operative manometry and intra-operative EndoFLIP in identifying patients at risk of developing dysphagia post-operatively.

Transthoracic Approach to Reoperative Antireflux Surgery

Reoperative antireflux surgery (ARS) is complex and often needs to be customized to the individual patient. A transthoracic approach is preferred in select patients with concomitant esophageal pathologies or a complex surgical history. The clinical presentation and perioperative evaluation of patients who require reoperative ARS as well as surgical options, the role of the transthoracic approach, and Nissen and Belsey Mark IV fundoplication techniques are discussed in detail. Outcomes associated with the transthoracic approach to reoperative ARS are reviewed. Although less invasive laparoscopic approaches have become more common, the transthoracic approach must remain in the foregut surgeon’s armamentarium.

Quality of life and gastric acid-suppression medication post-laparoscopic fundoplication: a ten years retrospective study

Background: Although medical treatment is the best approach for treating gastroesophageal reflux disease (GERD), surgery has a significant role to play not only in cases of failure of medical treatment but also as in a long-term approach, specifically in young patient. On the other hand, alarming reports have been published concerning the outcomes and usefulness of antireflux surgery (ARS). The aim of this study was to evaluate medium and long-term functional outcomes following ARS performed in our institution over a 10 year period. Methods: This was a retrospective review of patients in our department who underwent primary or redo laparoscopic fundoplication between 2005 and 2015. Evaluation of the outcomes was made using a validated questionnaire specifically dedicated to GERD (the Gastroesophageal Reflux Disease – Health-Related Quality of Life (GERD-HRQL) questionnaire) and by investigation about the continued use of proton-pump inhibitors (PPIs). Exclusion criteria were patients treated for GERD with Roux-en-Y gastric bypass, emergency reduction of hiatal hernia, patients missing from follow-up and patients deceased from unrelated causes. Results: 296 patients out of 309 met the inclusion criteria. Primary procedures included 214 Nissen, 35 Toupet, and 23 Collis gastroplasty; there were additionally 62 redo operations. Neither postoperative mortality nor conversion was observed. The mean follow-up was 8 years post-surgery, and contact was made with 96% of the original group. 85% of the patients had stopped PPI use since their operation (86% after Nissen, 73% after Toupet, 94% after Collis and 82% after redos). 90% of the patients had good to excellent functional results as reported by their GERD-HRQL score, and independent of the type of previous procedure. 31 patients were dissatisfied due to dysphagia in 7 and GERD recurrence in 24. Again 75% were extremely satisfied and 15% satisfied. Our own incidence of redo procedures was 11% but the functional result and satisfaction index were comparable between redo and primary procedures. The addition of Collis gastroplasty in cases of real short oesophagus did not alter the final result. Conclusions: Laparoscopic ARS presents a superior alternative to lifetime medication use and can provide long-term control of GERD symptoms in the majority of patients if it is performed skillfully and in carefully evaluated patients. Based on the present study, we believed that significant improvement in GERD health-related quality of life can be attained following both primary and reoperative ARS.

Quantifying physiologic parameters of the gastroesophageal junction during re-operative anti-reflux surgery.

Hiatal hernia re-approximation during index anti-reflux surgery (ARS) contributes approximately 80% of overall change in distensibility index (DI) and, potentially, compliance of the gastroesophageal (GEJ), while sphincter augmentation contributes approximately 20%. Whether this is seen in re-operative ARS is unclear. We quantify the physiologic parameters of the GEJ at each step of robotic re-operative ARS and compare these to index ARS. Robotic ARS with hiatal hernia repair was performed on 195 consecutive patients with pathologic reflux utilizing EndoFLIP™, of which 26 previously had ARS. Intra-operative GEJ measurements, including cross-sectional area (CSA), pressure, DI, and high-pressure zone (HPZ) length were collected pre-repair, post-diaphragmatic re-approximation, post-mesh placement, and post-lower-esophageal sphincter (LES) augmentation. Both cohorts were similar by sex and BMI and underwent similar procedures. The re-operative cohort was older (60.6 ± 15.3 vs. 52.7 ± 16.2years, p = 0.03), had more frequent pre-operative dysphagia (69.2% vs. 42.6%, p = 0.01) and esophageal dysmotility on barium swallow (75.0% vs. 35.0%, p < 0.001) but lower rates of hiatal hernia on endoscopy (30.8% vs. 68.7%, p < 0.001) compared to index procedures. Among the re-operative cohort, the CSA decreased by 34 (IQR - 80, - 15) mm2 and DI 1.1 (IQR - 2.4, - 0.6) mm2/mmHg (both p < 0.001). Pressure increased by 11.2 (IQR 4.7, 14.9) mmHg and HPZ by 1.5 (1,2) cm (both p < 0.001). These changes were similar to those seen in index ARS. Diaphragmatic re-approximation contributed to a greater percentage of overall change to the GEJ than did the augmentation procedure, with 72% of the change in DI occurring during hiatal closure, similar to that seen during index ARS. During re-operative ARS, dynamic intra-operative monitoring can quantify the effects of each operative step on GEJ physiologic parameters. Diaphragmatic re-approximation appears to have a greater effect on GEJ physiology than does LES-sphincter augmentation during both index and re-operative ARS.

Robotic Reoperative Anti-reflux Surgery: Low Perioperative Morbidity and High Symptom Resolution.

Laparoscopic reoperative anti-reflux surgery (ARS) has a significantly higher morbidity than laparoscopic primary ARS; however, it is not known whether the same pattern exists within the robotic approach. We aimed to evaluate the safety and efficacy of robotic reoperative ARS in comparison with primary robotic ARS. A retrospective review of patients undergoing primary or reoperative robotic ARS at a tertiary referral center between 2012 and 2017 was performed. Perioperative outcomes and long-term symptom resolution were evaluated. A total of 200 patients were included (38 reoperative and 162 primary ARS). Baseline characteristics were comparable across groups. Seven (18.4%) of the reoperative patients had two or more prior foregut operations. Patients in the reoperative group had a longer operative time (226 vs. 180min, p < 0.001). There were no conversions to open technique, and one patient in the reoperative group (2.6%) had an intraoperative perforation. Twenty of the 38 reoperative patients (52.6%) were discharged within 24h as compared to 109/162 primary patients (64.9%) (p = 0.09). The readmission rate and postoperative complication rates were 6 and 3%, respectively, and did not differ between groups. At a mean follow-up of 1year, complete or partial resolution of preoperative symptoms was achieved in 97% of primary patients and 100% of reoperative patients (p = 0.4). The robotic approach allows for minimal morbidity, short length of stay, and excellent functional outcomes in patients undergoing reoperative ARS when compared to patients undergoing primary ARS.

Mo1013 - A Case for the Robot: Comparing Outcomes of Robotic Reoperative and Primary Antireflux Surgery

Mo1013 - A Case for the Robot: Comparing Outcomes of Robotic Reoperative and Primary Antireflux Surgery

Primary and Redo Antireflux Surgery: Outcomes and Lessons Learned

IntroductionSome patients require one or more reoperative interventions after undergoing primary antireflux surgery (ARS). We compared outcomes after primary and reoperative ARS. MethodsWe queried a prospectively maintained database to identify patients who underwent ARS from September 23, 2003 to May 28, 2016. Patients were categorized into four groups: A (primary ARS), B (first reoperative ARS), C (second reoperative ARS), or D (≥ third reoperative ARS). Patients completed follow-up foregut symptom surveys and satisfaction questionnaires at regular intervals. ResultsIn total, 940 patients were studied (A: n = 545, B: n = 302, C: n = 80, D: n = 13). Age, sex, and BMI were comparable across groups. Heartburn was the most common preoperative symptom in A, whereas dysphagia was more common in B–D. Open approach, mean operative time, and mean blood loss increased from A to D (P < 0.05), as did need for Roux-en-Y reconstruction. Vagal injury (2–19–33–54%; P < 0.05), visceral perforation (2–20–36–23%; P < 0.05), postoperative leak (0.2–2–6–8%; P < 0.05 A vs. all), and morbidity (2–10–14–39%; P < 0.05) also increased from A to D. At mean follow-up of 36 months, the proportion of patients who reported no significant symptoms, excellent satisfaction, and likeliness to recommend this surgery to a friend progressively declined with each successive reintervention (P < 0.05). ConclusionsComplications and patient-reported outcomes worsen with each reoperative ARS.

Laparoscopic Reoperative Antireflux Surgery Is More Cost-Effective than Open Approach

We previously reported on the outcomes of laparoscopic and open reoperative antireflux surgery. The aim of this study was to compare the costs of these procedures. We performed a retrospective review. Financial and procedure coding data were obtained using a cost accounting system. There were 49 procedures in 46 patients (36 female and 10 male). There were 38 laparoscopic (including 4 conversions) and 11 open procedures (7 transabdominal repairs and 4 gastric-preserving Roux-en-Y esophagojejunostomy). Values are median and interquartile range (IQR) and mean costs. Median age was 54 years (IQR 49 to 67 years) for the laparoscopic group vs 56 years (IQR 50 to 65 years) for the open group (p= 0.675). Mean direct costs per case for the laparoscopic group vs open group were $12,655 vs $24,636 (p < 0.002); operating room costs: $3,788 vs $5,547 (p= 0.011); hospital room costs: $1,948 vs $6,438 (p < 0.005); and supply costs: $4,386 vs $5,386 (p= 0.077). Median duration of the operation for the laparoscopic group was 185 minutes (IQR 147 to 254 minutes) vs 308 minutes (IQR 259 to 416 minutes) for the open group (p < 0.002). Median length of stay for the laparoscopic group was 3 days (IQR 2 to 4 days) vs 9 days (IQR 8 to 14 days) for the open group (p < 0.001). There was no 30-day or in-hospital mortality. Excluding the 4 Roux-en-Y procedures, direct costs for the laparoscopic group (n= 38) were $12,655 vs $23,678 for the transabdominal group (n= 7) (p= 0.035); duration of operation: 185 minutes (IQR 147 to 254 minutes) vs 292 minutes (IQR 218 to 309 minutes) (p= 0.003); and length of stay: 3 days (IQR 2 to 4 days) vs 9 days (IQR 7 to 15 days) (p= 0.017). There were 3 recurrences in the laparoscopic group. Two were repaired laparoscopically and 1 required a gastric-preserving Roux-en-Y esophagojejunostomy because the patient had undergone 2 earlier failed repairs. Including the cumulative costs of 3 recurrent hiatal hernia repairs, the driving force to reduce costs remained length of stay, manifested by the costs of the hospital rooms. Laparoscopic reoperative antireflux surgery is more cost-effective than open repair. The laparoscopic approach, when feasible, should be considered the surgical option for treatment of recurrent hiatal hernia in specialized esophageal centers with highly experienced surgical teams.

560 - Primary and Reoperative Antireflux Surgery: Outcomes and Lessons Learned

560 - Primary and Reoperative Antireflux Surgery: Outcomes and Lessons Learned

Mo1042 - Roux-En-Y Reconstruction Gives Better Symptom Relief than Redo Fundoplication in a Subset of Patients Undergoing Reoperative Antireflux Surgery

Mo1042 - Roux-En-Y Reconstruction Gives Better Symptom Relief than Redo Fundoplication in a Subset of Patients Undergoing Reoperative Antireflux Surgery

Laparoscopic reoperative antireflux surgery: A safe procedure with high patient satisfaction and low morbidity

BackgroundLaparoscopic reoperative antireflux surgery remains challenging and the advantages compared to an open approach remain unclear. MethodsRetrospective chart review and follow-up questionnaire via phone. Results50 reoperative hiatal hernia repairs were performed in 47 patients. Values: median and interquartile range (IQR). There were 10 males, 37 females, 55 (49–66) years. Reoperative procedures: 38 laparoscopic vs. 12 open transabdominal. Length of operation: 185 (147–254) vs. 325 (276–394) minutes (p < 0.0008). Length of stay: 3 (2–4) vs.10 (8–13) days (p < 0.0001). None required Collis gastroplasty. There was no 30-day mortality. Follow-up questionnaire was obtained in 36/45 (80%) at 21 (11–40) months (2 cancer related deaths). In all, 24/36 (67%) were free of preoperative symptoms and 33/36 (92%) were satisfied with the operation. There was no difference between the laparoscopic and open group. ConclusionsLaparoscopic reoperative antireflux surgery is a safe approach with high patient satisfaction and low morbidity. Tension-free esophageal length can be achieved laparoscopically without Collis gastroplasty. The duration of the operation and length of stay are less in the laparoscopic vs. open group. Symptomatic relief and patient satisfaction are similar in both approaches.

A proposed classification for uniform endoscopic description of surgical fundoplication

Objective assessment of postfundoplication anatomy is of utmost importance especially if reoperative intervention is being planned. There is a lack of uniformity in the description of endoscopic findings in these patients.The purpose of this study was to propose a classification for standardized endoscopic reporting of postfundoplication anatomy. After institutional review board approval, preoperative endoscopic findings of patients who underwent reoperative intervention from 1992 to 2011 were reviewed a nd classified. The classification included four factors:E (distance of GEJ to crus), S (amount of gastric tissue between the GEJ and fundoplication), F (fundoplication configuration), and P (paraesophageal hernia). The endoscopic findings of 310 patients who underwent reoperative antireflux surgery were classified using the newly proposed classification model. A significant increase in the number of procedures was noted over the years.There was no change in presenting symptoms and patterns of failure over the years. The classification model was easily applicable to previous endoscopy reports. There was good symptom association with our classification model. An endoscopic anatomical classification is proposed for description of failed fundoplication. With this classification, we hope to fill the gap in developing a uniform classification of failed fundoplications. Further studies addressing widespread applicability and outcome analysis are needed.

Roux-en-Y reconstruction is superior to redo fundoplication in a subset of patients with failed antireflux surgery

A subset of patients requires reoperative antireflux surgery (Re-ARS) after failed fundoplication. The aim of this study was to determine symptomatic outcomes beyond 1 year following Re-ARS and to assess the relative utility of two different surgical approaches. After Institutional Review Board approval, patients who underwent Re-ARS were identified from a prospective database. Symptom severity was graded on a 0-3 scale. Patients with postoperative symptoms of grade ≥ 2 were considered to have a poor outcome. Patient satisfaction was graded using a 10-point visual analog scale. At least 1 year of follow-up was available for 130 patients. There were 94 redo fundoplications (RF) and 36 Roux-en-Y reconstructions (RNYR). Symptom risk factors (significant preoperative dysphagia, significant preoperative heartburn, esophageal dysmotility, short esophagus, delayed gastric emptying, multiple failed hiatal surgeries, reflux-related respiratory symptoms) were more prevalent in patients who underwent RNYR compared to RF (mean 3.0 vs. 2.2; p = 0.003). Postoperative leaks and major complications occurred in 4.5 % (5/110) versus 0% and 21.6 % versus 33.3 % of the RF and RNYR groups, respectively. Twenty-eight RF patients (29.8 %) and 9 RNYR patients (25.0 %) reported poor outcomes. Among patients with ≥ 4 risk factors, those who underwent RNYR had a lower incidence of poor outcome (7.7 % vs. 55 %, p = 0.018) and higher satisfaction scores (8.4 vs. 5.8, p = 0.001) compared to those who had RF. Overall, 85 % of patients were satisfied or highly satisfied with their results and the average satisfaction score was 8.2. Re-ARS provides good subjective outcomes when measured more than 1 year after surgery. Patients with more complex pathology benefit more from RNYR despite the higher postoperative complication rate. This is especially true for patients with decreased esophageal motility and short esophagus.

Outcomes of surgical management of symptomatic large recurrent hiatus hernia

Recurrent hiatus hernia is frequently found in patients undergoing reoperative antireflux surgery. The objective of this study is to report perioperative complications and subjective and objective outcomes for patients who underwent reoperative intervention for symptomatic large recurrent hiatus hernia. Retrospective review of a prospectively maintained database was performed to identify patients with large (≥ 5 cm gastric tissue above the crus) recurrent hiatus hernia who underwent reoperation after failed antireflux surgery. Data for preoperative workup, operative procedure, and postoperative 6-month follow-up were reviewed and analyzed. Two hundred twenty patients underwent reoperation over a 6-year period. Forty-four patients had large recurrent hiatus hernia; 21 underwent redo fundoplication, while 23 underwent Roux-en-Y (RNY) reconstruction as remedial procedure. Short esophagus was found in 16 cases (6 of 21 redo Collis fundoplications, 10 of 23 RNY reconstructions). There was significant symptom improvement and high degree of satisfaction reported in both groups. However, patients with short esophagus did better with RNY reconstruction compared with redo Collis gastroplasty. Repair of large recurrent hiatus hernia is a technically challenging procedure; however, there is high degree of symptom resolution and patient satisfaction. RNY reconstruction might be a better alternative in patients with short esophagus compared with redo Collis gastroplasty.

Reoperative Antireflux Surgery for Failed Fundoplication: An Analysis of Outcomes in 275 Patients

With an increase in the performance of laparoscopic antireflux procedures, more patients with a failed primary antireflux operation are being referred to thoracic surgeons for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery. We conducted a retrospective review of patients who underwent redo surgery for failed fundoplication. The primary endpoint was failure of the redo operation; other endpoints included gastroesophageal reflux disease-health-related quality of life (HRQOL) after redo fundoplication. A total of 275 patients (median age, 52 years; range, 17 to 88 years; men 82, women 193) underwent redo antireflux surgery. The most common pattern of failure of the initial operation was transmediastinal migration-recurrent hernia in 177 patients (64%). Redo surgery included Nissen fundoplication in 200 (73%), Collis gastroplasty in 119 (43%), and partial fundoplication in 41 (15%). There was no perioperative mortality. At a median follow-up of 39.6 months, 31 patients (11.2%) had a failure of the redo surgery, requiring reoperation. The two-year estimated probability of freedom from failure was 93% (95% confidence interval 89% to 96%). The HRQOL scores, available for 186 patients, were excellent to satisfactory in 85.5%, and poor in 14.5%. Redo antireflux surgery can be performed safely in experienced centers with outcomes that are similar to published open results. Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of the procedure. Thoracic surgeons with significant laparoscopic and open esophageal surgical experience can perform minimally invasive, complex redo esophageal antireflux procedures safely with good results.

Reoperative antireflux surgery for dysphagia

Troublesome dysphagia is a common indication for redo antireflux surgery (Re-ARS). This study is aimed to analyze the efficacy of Re-ARS in resolving dysphagia and to identify risk factors for persistent or new-onset dysphagia after Re-ARS. A prospectively maintained database was retrospectively reviewed to identify patients after Re-ARS. Dysphagia severity was graded on a scale of 0 to 3 before and after Re-ARS based on responses to a standardized questionnaire. Patients reporting grade 2 or 3 symptoms were considered to have significant dysphagia. Satisfaction was graded using a 10-point analog scale. Between December 2003 and July 2008, 106 patients underwent Re-ARS. Significant preoperative dysphagia was reported by 54 patients, and impaired esophageal motility was noted in 31 patients. Remedial surgery included redo fundoplication (n = 87), Collis gastroplasty with redo fundoplication (n = 16), and takedown of the fundoplication or hiatal closure alone (n = 3). At least 1 year follow-up period (mean 21.8 months) was available for 92 patients. For patients with significant preoperative dysphagia (n = 46), the mean symptom score declined from 2.35 to 0.78 (p < 0.0001). Persistent dysphagia was reported by 13 patients and new-onset dysphagia by 4 patients. No patients reported grade 3 dysphagia after Re-ARS. Dilations were used to treat 11 patients. Multivariate logistic regression analysis identified Collis gastroplasty (p = 0.03; adjusted odds ratio [OR], 5.74) and preoperative dysphagia (p = 0.01; adjusted OR, 6.80) as risk factors for significant postoperative dysphagia. The overall satisfaction score was 8.3, but certain subsets had significantly lower satisfaction scores. These subsets included patients with esophageal dysmotility (7.1; p = 0.04), patients who required Collis gastroplasty (7.0; p = 0.09), and patients with esophageal dysmotility who required Collis gastroplasty (5.0; p < 0.01). Although dysphagia is a common symptom among patients requiring Re-ARS, intervention provides a significant benefit. Patients with preoperative dysphagia, especially those requiring Collis gastroplasty, are at increased risk for persistent dysphagia and decreased satisfaction after Re-ARS.

Laparoscopic Revision of Failed Fundoplication and Hiatal Herniorraphy

The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication. Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006. A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication. Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%). Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

Vagotomy During Hiatal Hernia Repair: A Benign Esophageal Lengthening Procedure

IntroductionThis study describes the use of vagotomy in patients during complex laparoscopic esophageal surgery (e.g., reoperative antireflux surgery (rLARS) or paraesophageal hernia (PEH) repair) when, after extensive esophageal mobilization, the gastroesophageal junction cannot be made to reach the abdomen without tension. In doing so, we hope to understand the risk incurred by vagus nerve division in this setting in order to evaluate its role in managing the short esophagus. MethodsOne hundred and sixty-six patients underwent rLARS or PEH repair between 1/1998 and 6/2003 at our institution. Clinical data was obtained from a prospectively maintained database and systematic patient questionnaires administered for this study. Follow-up was available for 102 (61%) of these patients, at a median of 19 months (range 6–69 months). ResultsFifty-two patients underwent rLARS while 50 patients underwent PEH repair. Thirty patients had a vagotomy during the course of their operation (Vag Group; 20 anterior, six posterior, four bilateral), 13 in the rLARS group (25%), and 17 in the PEH group (34%). The primary presenting symptoms for rLARS and PEH repair patients were improved in 89% in the Vag Group and 91% in the No Vag Group. Similarly, there was no difference in the severity of abdominal pain, bloating, diarrhea, or early satiety between the Vag and No Vag groups at follow-up. No patient required a subsequent operation for gastric outlet obstruction. ConclusionsVagotomy during rLARS and PEH repair does not lead to a higher rate delayed gastric emptying, dumping syndrome, or other side effects. Thus, we propose vagotomy to be a legitimate alternative to Collis gastroplasty when extensive mobilization of the esophagus fails to provide adequate esophageal length.

Subjective results and symptomatic outcome after fundoplication revision

Objective. In a small proportion of patients, fundoplication fails and a reoperation is required. However, there are few reports on the symptomatic outcome after reoperative antireflux surgery. The aim of this study was to evaluate the results after fundoplication revision. Material and methods. All patients (n=71) undergoing fundoplication revision between 1997 and 2005 were included in this study. The follow-up data were collected both from the hospital records and during postoperative control visits, including a personal interview using a structured questionnaire; follow-up was completed by 61 patients (88.4%). Results. The primary fundoplications included both open (n=21) and laparoscopic (n=40) approaches; 92% (n=56) of the reoperations were open procedures. The morbidity rate was 21% and the reoperation rate 16%. Fifty-six percent (n=34) of the patients regarded the result of their reoperative surgery as excellent, good or satisfactory at a mean follow-up of 51 months; 66% of the patients had no significant reflux symptoms after refundoplication. With the benefit of hindsight, 77% of the patients would again choose to undergo refundoplication, but only 48% of the patients would again primarily choose surgical treatment. Mortality rate was 1.4% (n=1) and in three patients the reoperative treatment required total gastrectomy. Conclusions. These suboptimal results show that surgical treatment for gastro-oesophageal reflux disease in general is far from being perfect and this is even more marked after reoperative antireflux surgery, as fundoplication revision can result in severe complications. This emphasizes the importance of proper patient selection for both initial and reoperative antireflux surgery.