Laparoscopic reoperations after failed and complicated antireflux operations

CT characterization of retractor related liver injuries after pancreaticoduodenectomy: Retrospective analysis of a single institution experience

PURPOSE

Retractor related liver injuries (RRLI) are reported after upper gastrointestinal tract surgeries; most commonly laparoscopic cholecystectomy and gastric surgeries. The aim of this study was to characterize the incidence, identification, type, severity, clinical features and risk factors for RRLI after open and robotic pancreaticoduodenectomy.

METHODS

A 6-year retrospective study of 230 patients was performed. Clinical data was extracted from the electronic medical record. Post-operative imaging was reviewed and graded using the American Association for the Surgery of Trauma (AAST) liver injury scale.

RESULTS

109 patients met eligibility criteria. RRLI occurred in 23/109 (21.1%), with a higher incidence in the robotic/combinedapproach (4/9) compared with open (19/100). Most common injury was an intraparenchymal hematoma (56.5%), grade II (78.3%), located in segments II/III (77%). 39.1% of injuries were not reported on the CT interpretation. There was a statistically significant elevation of postoperative AST/ALT in the RRLI group [median AST 219.5 vs. 72.0 (p < 0.001), ALT 203.0 vs. 69.0 (p < 0.001)]. Trends toward lower preoperative platelet counts and longer operations were observed in the RRLI group. No significant difference in hospital length of stay or post-operative pain scores were noted.

CONCLUSION

RRLI occurred frequently after pancreaticoduodenectomy, however most injuries were low grade and the only clinical significance was a transient increase in transaminases. A trend toward higher injury rates was observed in robotic cases. In this population, RRLI was often unrecognized on postoperative imaging.

Endoscopic clipping of the Z-line (CMZL) helps recognize anatomical failures after Nissen fundoplication: technical report of a new method

Introduction

Nearly 15% of patients after laparoscopic antireflux surgery experience recurrence of symptoms or develop new gastrointestinal symptoms. Some of them require redo procedures. It can be demanding to reveal anatomical failure after previous fundoplication.

Aim

To present a method which assists in recognition of anatomical failures after Nissen fundoplication.

Material and methods

Five patients with previous laparoscopic Nissen fundoplication and severe gastrointestinal symptoms were included in this study. During the esophagogastroduodenoscopy (EGDS) two radiopaque metal clips were placed to mark the Z-line (“clips-marked Z-line” – CMZL). It was done to achieve precise visualization of the gastroesophageal junction area in the video contrast investigation. Distinctions between conclusions after the EGDS, ordinary video contrast investigation, video contrast investigation with CMZL and intraoperative findings were analyzed.

Results

All patients underwent laparoscopic refundoplication with good postoperative results. There were 4 cases misdiagnosed by contrast investigation without clips and four cases misdiagnosed by EGDS. Endoscopic clipping helped to recognize correctly all anatomical failures.

Conclusions

Applying CMZL as a routine investigation before redo fundoplication can reduce frequency of misdiagnosis and help to perform redo fundoplication in appropriate patients, but it requires further studies on larger cohorts of patients.

Re-operation for failed gastro-esophageal fundoplication. What results to expect?

The aim of this study is to evaluate short and medium term results of re-operation for failed fundoplication in a retrospective monocentric cohort of 47 patients.

PATIENTS AND METHODS

Between 1995 and 2011, 595 patients underwent a laparoscopic primary fundoplication (PFP) for gastroesophageal reflux disease (GERD). During the same period, 47 patients required a re-operative fundoplication (RFP). In 11 patients, the original wrap had herniated into the thorax. All these revisions consisted of a complete takedown of the original wrap before constructing a tension-free wrap using a standardized technique. Patients with a follow-up of at least 2 years were matched to patients who had been operated only once to assess satisfaction and quality of life.

RESULTS

Short term: All patients were operated by laparoscopy with no conversion. There was no mortality. Two postoperative complications necessitating re-operation were observed (morbidity 4.3%): one complete aphagia and one gastric perforation. Long term: 29 re-operated patients with a follow-up of at least 2 years (mean: 4,5 years) (Group RFP) were compared to a matched group of 29 patients operated only once (Group PFP). These groups were comparable in age, sex ratio, BMI and follow-up. In both groups, all patients were operated by laparoscopy without conversion. Morbidity was 3.5% in the RFP group, none in the PFP group. There was no mortality in either group. The length of stay and operative time were significantly higher in the RFP group (4.6 vs. 2.6 days, p<0.05). Two RFP patients (5%) required re-operation at three and seven months vs. none in the PFP group. The long-term satisfaction was comparable in the two groups (78% vs. 85%, p=NS). Quality of life assessed by the GIQLI was significantly better in the PFP group (104 vs. 84, p<0.05).

CONCLUSION

Re-do fundoplication is a safe procedure and is feasible by laparoscopy. In the long-term, patient satisfaction is comparable to primary intervention with, however, a slightly poorer quality of life.

Laparoscopic revision of failed antireflux surgery: a systematic review

BACKGROUND

Laparoscopic antireflux surgery is an accepted treatment for persistent gastroesophageal reflux but about 4% of patients will eventually require revision surgery.

METHODS

We searched The Cochrane Collaboration, Medline, and EMBASE databases, augmented by Google Scholar and PubMed related articles from January 1, 1990, to November 22, 2010. Twenty studies met the inclusion criteria, reporting on 930 surgeries.

RESULTS

The mean surgical duration was 166 minutes and conversion to open revision fundoplication was required in 7% of cases. Complications were reported in 14% of cases and the mean length of stay varied between 1.2 and 6 days. A good to excellent result was reported for 84% of surgeries and 5% of patients required a further revisional procedure.

CONCLUSIONS

Laparoscopic revision antireflux surgery appears to be feasible and safe, but subject to somewhat greater risk of conversion, higher morbidity, longer hospital stay, and poorer outcomes than primary laparoscopic fundoplication.

Endoscopic assessment of failed fundoplication: a case for standardization

BACKGROUND

Preoperative endoscopic assessment of the failed fundoplication is instrumental in diagnosis and surgical management. Endoscopy is a routine and essential part of the workup for a failed fundoplication, but no clear guidelines exist for reporting endoscopic findings. This study aimed to compare endoscopic findings reported by community physicians (gastroenterologists and surgeons) with the findings of the authors (esophageal center) for patients who underwent reoperative intervention after a previous antireflux procedure.

METHODS

Retrospective review of a prospectively maintained database was performed to identify patients who underwent reoperation after a failed antireflux operation between 1 December 2003 and 30 June 2010. Endoscopic findings as reported by the outside physician and by the esophageal center endoscopist were reviewed and compared.

RESULTS

During the study period, 229 patients underwent reoperation. Of these patients, 20 did not have endoscopy performed by an outside physician and were excluded from the study, leaving 208 patients. The endoscopic reports of the esophageal center physician included 97 cases of hiatal hernia (64 type 1 and 33 types 2 and 3), 52 slipped fundoplications, 61 disrupted fundoplications, 30 intrathoracic fundoplications, 25 twisted fundoplications, 14 two-compartment stomachs, and 27 cases of Barrett's esophagus. Outside physicians identified 68% of the hiatal hernias and 61% of the paraesophageal hernias reported by the authors. Only 32% of the outside reports mentioned a previous fundoplication. Furthermore, only 17% of the slipped fundoplications and 30% of the disrupted fundoplications were so described. Outside physicians identified 19 of the 27 patients with Barrett's esophagus.

CONCLUSION

Fundoplication changes described by the general endoscopist are inadequate. With an increasing population of patients who have undergone prior antireflux surgery, incorporation of fundoplication assessment in an endoscopic curriculum may be helpful.

Thoracotomy versus transhiatal esophageal dissection: which is the best surgical approach to short esophagus?

PURPOSE

To evaluate different approaches performed to obtain a more significant esophageal length.

METHODS

An experimental model using 28 cadavers was conceived. Randomized groups: Group A (n=10) underwent laparotomic transhiatal approach; Group B (n=9) which differed from the first in the conduction of a wide phrenotomy and Group C (n=9) esophageal dissection was performed through a left anterolateral thoracotomy.

RESULTS

Final length variations for Group A were 2.12cm and 3.29cm and for Group B 3.24 cm and 3.66cm, without and with esophageal traction, respectively. In Group C length gain observed was 3.81 cm. The mediastinal dissections conducted through the hiatus was considered the procedure that produced the better esophageal mobilization, and the association of wide phrenotomy significantly improved the results.

CONCLUSION

The mediastinal dissection was the most effective to improving gain in abdominal esophagus. When toracotomy and laparotomy were compared, no significant differences were observed in the outcome.

Minimally invasive esophagectomy is safe and effective following neoadjuvant chemoradiation therapy

BACKGROUND

Minimally invasive esophagectomy (MIE) is technically demanding, and implementation has been hindered by a steep learning curve. Despite widespread concern about the successful performance of this procedure following neoadjuvant chemoradiotherapy (NACR) treatment, we hypothesized that safe and effective MIE could be performed in this setting.

MATERIALS AND METHODS

We reviewed our prospective database of patients undergoing MIE for esophageal cancer at our institution between January 2008 and February 2010. We analyzed the association of NACR on perioperative outcomes and compared them with those patients undergoing MIE without NACR. NACR was used in ≥T2 or N+ tumors.

RESULTS

A total of 61 consecutive patients underwent a planned MIE. A complete MIE or hybrid procedure was performed in 58 patients (95%), while 3 patients were unresectable. Median age was 67 years (range 38-85). Anastomoses were performed in the cervical region in 47 patients (81%) while 11 patients had an anastomosis in the right chest. Serious complications included: 3 cervical anastomotic leaks (5%), 2 thoracic duct leaks (4%), 12 pneumonias (21%), 10 atrial fibrillations (18%), and 1 death in a patient not undergoing NACR. NACR was used in 41 patients. There was no significant difference in estimated blood loss (EBL), complications, or negative pathologic margins in patients undergoing NACR with MIE vs. MIE alone (P=NS). Median number of lymph nodes excised and PostOp LOS was 15 and 11 in patients undergoing NACR compared with 13 and 9 in those undergoing MIE alone (P=NS).

CONCLUSION

MIE is safe following NACR. Excellent results can be achieved with this operation in patients with advanced tumors.

Roux-en-Y reconstruction for failed fundoplication

BACKGROUND

Redo fundoplication has acceptable outcomes in patients with failed previous fundoplications. However, a subset of patients require Roux-en-Y (RNY) reconstruction for symptom relief.

AIM

The aim of this study was to demonstrate safety and efficacy of RNY reconstruction for failed fundoplications.

METHOD

Retrospective review of data on patients who underwent short-limb RNY gastrojejunostomy (GJ) or esophagojejunostomy (EJ) between the years 2005 and 2007 was performed.

RESULTS

Twenty-two patients underwent RNY reconstructions. Fourteen (64%) patients had one, six (27%) patients had two, and 2 (9%) patients had three previous anti-reflux procedures. RNY GJ was performed in 18 patients and EJ in four patients. Gastrectomy was performed in 13 of these patients. Seven patients (32%) had ten major or minor complications within the 30-day postoperative period, without any mortality observed. At a mean follow-up of 23 months, completed in 21 of these patients (95%), the average heartburn score was 0.38 (range, 0-2). The average regurgitation score was 0.23 (range, 0 to2) and the average dysphagia score was 0.7 (range, 0-2). The mean postoperative BMI was 25.4 compared to a preoperative BMI of 31.

CONCLUSION

RNY reconstruction with GJ or EJ for failed anti-reflux procedures is a safe, valid surgical option in difficult situations, where a redo fundoplication is either non-feasible or expected to fail. However, it is associated with higher morbidity.

Laparoscopic revision of failed fundoplication and hiatal herniorraphy

OBJECTIVE

The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication.

BACKGROUND

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.

METHODS

A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication.

RESULTS

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%).

CONCLUSION

Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

Surgical reintervention after failed antireflux surgery: a systematic review of the literature

BACKGROUND

Outcome and morbidity of redo antireflux surgery are suggested to be less satisfactory than those of primary surgery. Studies reporting on redo surgery, however, are usually much smaller than those of primary surgery. The aim of this study was to summarize the currently available literature on redo antireflux surgery.

MATERIAL AND METHODS

A structured literature search was performed in the electronic databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

RESULTS

A total of 81 studies met the inclusion criteria. The study design was prospective in 29, retrospective in 15, and not reported in 37 studies. In these studies, 4,584 reoperations in 4,509 patients are reported. Recurrent reflux and dysphagia were the most frequent indications; intraoperative complications occurred in 21.4% and postoperative complications in 15.6%, with an overall mortality rate of 0.9%. The conversion rate in laparoscopic surgery was 8.7%. Mean(+/-SEM) duration of surgery was 177.4 +/- 10.3 min and mean hospital stay was 5.5 +/- 0.5 days. Symptomatic outcome was successful in 81.1% and was equal in the laparoscopic and conventional approach. Objective outcome was obtained in 24 studies (29.6%) and success was reported in 78.3%, with a slightly higher success rate in case of laparoscopy than with open surgery (85.8% vs. 78.0%).

CONCLUSION

This systematic review on redo antireflux surgery has confirmed that morbidity and mortality after redo surgery is higher than after primary surgery and symptomatic and objective outcome are less satisfactory. Data on objective results were scarce and consistency with regard to reporting outcome is necessary.

Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility

OBJECTIVE

To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication and to evaluate the success rate of these procedures. Nissen fundoplication (360 degrees ) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been recommended to use the Toupet procedure (270 degrees ) in these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia).

METHODS

200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview, endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry.

RESULTS

After two years 85% (Nissen) and 85% (Toupet) of patients were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication compared to Toupet (19 vs. 8, p < 0.05) and did not correlate with preoperative motility. Concerning reflux control the Toupet proved to be as good as the Nissen procedure.

CONCLUSION

Tailoring antireflux surgery according to the esophageal motility is not indicated, as motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation as it has a lower rate of dysphagia and is as good as the Nissen fundoplication in controlling reflux.

[Relaparoscopy as an alternative to laparotomy for laparoscopic complications]

In the field of visceral surgery, complications requiring reintervention following laparoscopy are currently most likely to be approached with conventional laparotomy. However, relaparoscopy has the theoretical advantage of maintaining the reduced morbidity allowed by the first procedure. Essential to the success of relaparoscopy is a clear understanding of the various specific complications. Should the surgeon decide on relaparoscopy, then prompt action is of central importance. Following laparoscopic cholecystectomy, it is fundamentally technically possible through renewed laparoscopy to treat not only subhepatic abscesses but also smaller lesions of the bile duct, for example from the gall bladder fossa. Revision of complications following fundoplication is technically very demanding and should be performed only by those most experienced in the techniques of laparoscopy. In contrast to interventional drainage, relaparoscopy of abscesses following laparoscopic appendectomy has the theoretical advantage of allowing recognition and treatment of the causes, for example in the case of appendicular stump insufficiency. Relapses very shortly after endoscopic surgery of inguinal herniae result from erroneous technique and may be corrected endoscopically in most cases. Complications following colon surgery have so far been dealt with using open surgery for technical reasons and also for patient safety. Given the uncertainty in the literature, patient safety must be paramount, when deciding on which technique is best to employ, particularly in cases of haemorrhage.

Laparoscopic Collis Gastroplasty and Nissen Fundoplication for Reflux Esophagitis With Shortened Esophagus in Japanese Patients

BACKGROUND

There is an extremely small number of surgical cases of laparoscopic Collis gastroplasty and Nissen fundoplication (LCN procedure) in Japan, and it is a fact that the surgical results are not thoroughly examined.

PURPOSE

To investigate the results of LCN procedure for shortened esophagus.

PATIENTS AND METHODS

The subjects consisted of 11 patients who underwent LCN procedure for shortened esophagus and followed for at least 2 years after surgery. The group of subjects consisted of 3 men and 8 women with an average age of 65.0+/-11.6 years, and an average follow-up period of 40.7+/-14.4 months. Esophagography, pH monitoring, and endoscopy were performed to assess preoperative conditions. Symptoms were clarified into 5 grades between 0 and 4 points, whereas patient satisfaction was assessed in 4 grades. The use of postoperative acid-reducing medication and the recurrence of esophagitis were also investigated.

RESULTS

None of the patients experienced intraoperative complications, received transfusions, required conversion to open surgery, or died postoperatively. The average preoperative heartburn, regurgitation, and dysphagia scores were 2.36+/-1.29, 2.27+/-1.19, and 1.82+/-1.78 points, respectively. These scores improved after surgery to 0.55+/-1.21 (P=0.0063), 0.55+/-1.21 (P=0.0094), and 1.0+/-1.18 (P=0.1236) points, respectively. All patients had esophagitis preoperatively, which recurred in 3 patients (27%). In these 3 patients, acid-secreting mucosa was confirmed on the oral side of the wrap, by positive Congo-red staining. Hiatal hernia recurred in one patient, who also experienced recurrent esophagitis. Five patients received acid-reducing medication postoperatively. The degree of satisfaction was excellent in 2, good in 6 patients, fair in 2, and poor in 1 patient(s).

CONCLUSIONS

Although the LCN procedure can be performed safely, the outcome was not necessarily satisfactory. The LCN procedure requires avoidance of residual acid-secreting mucosa on the oral side of the wrapped neoesophagus. If acid-secreting mucosa remains, continuous acid suppression therapy should be employed postoperatively.

Repair of 104 failed anti-reflux operations

OBJECTIVE

To assess whether reoperative surgery for failed Nissen fundoplication is beneficial and to classify all mechanisms of failure recognized.

SUMMARY BACKGROUND DATA

Antireflux surgery is often necessary, but a 10% failure rate is commonplace. We report results for patients undergoing reoperative surgery and present a nomenclature of mechanisms of failure.

METHODS

A total of 104 patients, who had a previous fundoplication for gastroesophageal reflux disease (GERD), underwent reoperative surgery. Manometry (n = 86), endoscopy (n = 101), pH monitoring (n = 27), upright esophagram (n = 90), gastric emptying (n = 26), and symptom assessment (n = 104) were performed prior to reoperative surgery. Patients were also assessed before and during reoperation for mechanism of failure using a newly proposed classification. The operative approach was laparoscopic in 58 patients, via open laparotomy in 12, and a thoracotomy in 34 patients. Follow-up was conducted by phone interview and was completed in 97 patients (97%; 3 were deceased) with a mean follow-up of 32 months (range, 1-146 months).

RESULTS

The conversion rate to laparotomy for laparoscopic patients was 8%. The perioperative complication rate was 32%. One patient died of respiratory insufficiency after a laparotomy. Seven patients required additional surgery for correction of persistent or recurrent symptoms. The short and long-term complication rate was similar for the different operative approachs. Symptom resolution (rare or absent) occurred in 74% of patients with dysphagia, 75% with heartburn, 85% with regurgitation, and 94% with chest pain. The overall post-reoperative patient satisfaction was 7 on a scale of 1 to 10 and 3 on a scale of 1 to 4 when patients were asked to grade the operative result. There was no difference in the symptom resolution for patients operated upon by the laparoscopic approach as compared with laparotomy, but those patients undergoing a Collis gastroplasty had poorer results. The preoperative accuracy of assessment for mechanism of failure was 78%. A nomenclature of mechanisms of failure is included to aide reoperative assessment and new mechanisms of failure are described.

CONCLUSION

Reoperative surgery results for GERD are satisfactory. A variety of operative approaches proved equally effective. Poorer results were observed in patients with more advanced disease.

Management of esophageal symptoms following fundoplication

Laparoscopic antireflux surgery has emerged as a widely used and effective management option for the properly selected patient with gastroesophageal reflux disease. Poor symptomatic outcomes occur even in the best of hands, the most common being recurrent or persistent heartburn (or atypical symptoms) and dysphagia. When heartburn predominates, the initial management step is an anatomical and physiologic evaluation to determine whether acid reflux is controlled and if the postoperative neoanatomy is appropriate. If anatomical evaluation indicates surgical failure (eg, slipped or loose fundoplication, recurrent hiatal hernia), earlier re- operation may be warranted. Objective evidence of ongoing acid reflux or a reflux-symptom association despite anatomical integrity indicates reintroduction of antireflux medical therapy. Evidence favoring physiologic and anatomical success should direct treatment toward functional heartburn, including the use of tricyclic antidepressants. Dysphagia in the immediate postoperative setting mandates reassurance, as conservative measures alone often suffice while postoperative changes resolve. With persistent dysphagia, anatomical and physiologic evaluation is again indicated in the search for a mechanical-, motility-, or reflux-related symptom basis. Dilation techniques can prevent the need for re-operation, but persistent dysphagia associated with distorted postoperative anatomy will likely require surgical intervention. Regardless of the indication, re-operation carries substantial morbidity and reduced success rates compared with the initial procedure. These procedures mandate careful patient selection and referral to a center with thorough surgical experience.

Short Esophagus and Esophageal Stricture

Short esophagus and peptic esophageal stricture are complications of chronic severe GERD. Short esophagus is properly diagnosed by an objective,intraoperative assessment after appropriate dissection of the GEJ. A laparoscopic Collis gastroplasty combined with an antireflux procedure comprises effective therapy. Peptic stricture should be addressed with an initial course of dilator therapy and optimization of antiacid medication. Consideration is given to an antireflux procedure if conservative therapy fails. Laparoscopic techniques have proven to be safe and effective in treating short esophagus and peptic stricture.

Reoperative laparoscopic fundoplication for the treatment of failed fundoplication

OBJECTIVE

This study was undertaken to determine the safety and efficacy of reoperative laparoscopic fundoplication for patients with failed fundoplication.

METHODS

Thirty-nine of 612 consecutive patients who had undergone fundoplication underwent laparoscopic reoperative fundoplication for recurrent symptoms, persistent dysphagia, or gas bloat. An additional 15 patients were referred from outside facilities for reoperation. Preoperative evaluation included barium swallow (n = 54), esophagogastroduodenoscopy (n = 54), esophageal manometry (n = 34), and 24-hour ambulatory pH measurement (n = 32). Symptom severity before and after surgery was evaluated with a visual analog scoring scale. The mean follow-up was 22.5 months.

RESULTS

The primary symptoms that led to reoperation in the 54 patients were heartburn (n = 26), dysphagia (n = 23), and gas bloat (n = 5). Average time from initial operation to reoperation was 22.7 months. There were 3 conversions to open technique. An anatomic reason for the failure of the initial fundoplication was found in 69% of cases: slipped or misplaced fundoplication (n = 14), disrupted fundoplication (n = 8), transdiaphragmatic herniation (n = 7), achalasia (n = 1), and tight fundoplication (n = 7). Fourteen patients had 15 perioperative complications. Mean hospital stay was 2.3 days. Symptoms such as heartburn, dysphagia, and gas bloat improved significantly after reoperation; 40% to 50% of patients had scores 0 to 2, 21% to 45% had scores 3 to 7, and 9% to 29% had scores 8 to 10. Proton-pump inhibitor use after operation decreased from 88% to 36%. Fifty-two percent of patients completely discontinued any antireflux medications. Three patients had failure of the reoperation and required additional procedures.

CONCLUSION

Laparoscopic reoperation for failed fundoplication is feasible and can achieve resolution of symptoms for a significant percentage of patients.

Pregnancy and delivery after antireflux surgery

BACKGROUND

Concerns have been raised that subsequent pregnancy after antireflux surgery (ARS) may predispose to wrap disruption or herniation and adversely affect outcomes. Some surgeons withhold ARS in women of childbearing age for fear of this, but outcomes in this population have not been reported.

METHODS

All childbearing-age women who underwent ARS for gastroesophageal reflux disease (GERD) between January 1991 and July 2000 were asked to complete a detailed questionnaire. Patients with subsequent pregnancies (SP) after ARS were compared with patients without subsequent pregnancies (NP).

RESULTS

Ninety-five of the 118 patients (81%) completed the questionnaire at a mean follow-up of 4.9 years. Fifteen patients had 19 subsequent pregnancies after undergoing ARS, and retching and/or vomiting were reported during 13 of the pregnancies (69%). Preoperative incidence of complicated-GERD including strictures (11% vs. 20%), Barrett's esophagus (19% vs. 13%), esophagitis (36% vs. 33%), and ulceration (4% vs. 0%)-were similar between the nonpregnant and pregnant groups. Incidence of postoperative moderate to severe esophageal (7% vs. 8%) and extraesophageal symptoms (0% vs. 6%) were similar between the SP and NP groups. Postoperative prevalence of antisecretory medications was similar in SP and NP groups (13% and 23%, respectively). The incidence of fundoplications redone did not reach statistical difference between the NP (11%) and SP (0%) groups. Long-term outcomes and failure rates were similar in both groups, except the SP group reported greater overall satisfaction with ARS.

CONCLUSIONS

Women of childbearing age have a high incidence of complicated GERD, which may contribute to higher-than-expected rates of symptomatic and anatomic fundoplication failures than first-time ARS. Subsequent pregnancies do not adversely affect outcomes after ARS.

The management of patients who have "failed" antireflux surgery

Gastroenterologists may be called upon to manage patients who have had antireflux surgery that failed. The available literature on this topic comprises predominantly reports on retrospective, observational studies written by surgeons who often have focused on how technical deficiencies in performing the operation led to the failure. Such reports are of limited value to the gastroenterologist seeking guidance on patient management. Furthermore, comparisons among the reports are confounded by the lack of a standardized definition for failed antireflux surgery. This report critically reviews the available literature, and suggests a practical approach to the management of patients who have symptoms that were not completely relieved, that reappeared later, or that were caused by antireflux surgery.

Migração precoce da fundoplicatura após tratamento cirúrgico videolaparoscópico da doença do refluxo gastroesofágico

OBJETIVO: A cirurgia antirefluxo videolaparoscópica foi um avanço significativo no tratamento da doença do refluxo gastroesofagiano (DRGE), e tem baixo índice de complicações. O objetivo deste estudo é apresentar a experiência no tratamento de pacientes submetidos à correção do RGE por videolaparoscopia, que desenvolveram no pósoperatório precoce migração da válvula antirefluxo. MÉTODO: Foram estudados 869 pacientes submetidos à fundoplicatura e hiatoplastia por videolaparoscopia, para tratamento de DRGE, durante o período de março de 1995 a março de 2002. RESULTADOS: Seis pacientes (0,69%) tiveram migração da válvula no pósoperatório. O diagnóstico foi realizado basicamente pelo quadro clínico e estudo radiológico simples do tórax. Todos foram reoperados: dois por videolaparoscopia e quatro por laparotomia. O resultado final foi bom, com desaparecimento completo do refluxo gastro-esofagiano e ausência de óbitos. CONCLUSÕES:A migração da válvula anti-refluxo é complicação pouco frequente após fundoplicatura vídeo-laparoscópica. Seu diagnóstico e tratamento precoces garantem a boa evolução destes pacientes.

Transperitoneal laparoscopy into the previously operated abdomen: effect on operative time, length of stay and complications

PURPOSE

We evaluated the effect of previous abdominal surgery on perioperative outcomes in patients undergoing a renal/adrenal laparoscopic procedure via a transperitoneal approach.

MATERIALS AND METHODS

Renal/adrenal laparoscopic procedures via a transperitoneal approach were assessed. Medical records were reviewed to obtain operative and perioperative data.

RESULTS

Of the 190 patients 76 (40%) had previously undergone abdominal surgery. Patients with versus without an earlier abdominal operation had a longer mean hospital stay (3.8 versus 2.6 days, p = 0.002) but not longer median operative room time (median 220 versus 210 minutes, p >0.05). Operative and major complication rates were greater in patients with previous operations (16% versus 4%, p = 0.009 and 16% versus 5%, p = 0.022, respectively). Access and total complication rates were not altered (4% versus 2% and 33% versus 24%, respectively, p >0.1). An upper midline scar/ipsilateral upper quadrant scar was associated with a greater access complication rate (12% versus 0%, p = 0.029) but not a higher operative complication rate (21% versus 13%, p = 0.502). Multiple logistic regression confirmed that previous abdominal surgery was the only factor associated with operative complications.

CONCLUSIONS

Previous open abdominal operation increased the risk of operative and major complications, which most likely resulted in increased length of stay. The location of the scar impacted the access complication rate. Patients who have undergone previous open surgical procedures should be counseled on the greater risk of complications if the transperitoneal route is elected. Alternatively a retroperitoneal approach may be used.

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: quality of life, symptomatic outcome, and patient satisfaction

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluated using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery.

Nissen vs Toupet laparoscopic fundoplication

BACKGROUND

Nissen fundoplication (360 degrees ) is the standard operation for the surgical management of gastroesophageal reflux disease (GERD). To avoid postoperative dysphagia, it has been proposed that antireflux surgery be tailored according to the degree of preexisting esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and the Toupet procedure (270 degrees ) has been recommended for these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques in terms of reflux control and complication rate (dysphagia). Our objective was to determine the impact of preoperative esophageal motility on the clinical and objective outcome, following Toupet vs Nissen fundoplication and to evaluate the success rate of these procedures.

METHODS

From May 1999 until May 2000, 200 patients with GERD were included in a prospective randomized study. After preoperative examinations (clinical interview, endoscopy, 24-h pH study and esophageal manometry), 100 patients underwent either a laparoscopic Nissen (50 with and 50 without motility disorders), or a Toupet procedure (50 with and 50 without motility disorders). Postoperative follow-up after 4 months included clinical interview, endoscopy, 24-h pH study and esophageal manometry.

RESULTS

Interviews showed that 88% (Nissen) and 90% (Toupet) of the patients, respectively, were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication than after a Toupet (30 vs 11, p <0.001) and did not correlate with preoperative motility. In terms of reflux control, the Toupet proved to be as effective as the Nissen procedure.

CONCLUSION

Tailoring antireflux surgery to esophageal motility is not indicated, since motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation because it has a lower rate of dysphagia and is as effective as the Nissen fundoplication in controlling reflux.

Complications of laparoscopic antireflux surgery

Over the last decade, the laparoscopic approach to antireflux surgery has been widely applied, resulting in improved early outcomes and greater patient acceptance of surgery for gastroesophageal reflux disease. However, although short-term outcomes are probably better overall than those following open surgery, it has become apparent that the laparoscopic approach is associated with an increased risk of some complications, and as well as the occurrence of new complications specific to the laparoscopic approach. Significant complications include acute paraesophageal hiatus herniation, severe dysphagia, pneumothorax, vascular injury, and perforation of the gastrointestinal tract. The incidence of some of these complications decreases as surgeons gain experience; others can be minimized by using an appropriate operative technique. In addition, laparoscopic reintervention is usually straightforward in the 1st postoperative week. For this reason, the surgeon should have a low threshold for early laparoscopic reexploration, facilitated by early radiological contrast studies, in order to reduce the likelihood that problems will arise later.

[Immediate postoperative complications after a laparoscopic partial posterior fundoplication. Early laparoscopic reoperation]

AIM OF THE STUDY

The immediate postoperative course of laparoscopic partial posterior fundoplication can be complicated by severe dysphagia or paraesophageal hernia. The aim of this study was to describe the technical causes of these complications.

PATIENTS AND METHOD

Four patients, operated for gastroesophageal reflux disease by laparoscopic partial posterior fundoplication, developed severe dysphagia (n = 2) or paraesophageal hernia (n = 2) during the immediate postoperative period. A barium swallow examination visualized the complication in both cases of dysphagia and in 1 case of paraesophageal hernia. The correct diagnosis was established by CT scan in the other case of paraesophageal hernia. Reoperations were performed by laparoscopy, 3 days (n = 2) or 6 days (n = 2) postoperatively.

RESULTS

Dysphagia was due to compression of the esophagus against the hiatus by the fundoplication. A new and looser fundoplication was easily performed. Dysphagia was no longer present postoperatively. The two patients were symptom-free after 6 and 12 months of follow-up, respectively. In the cases of paraesophageal hernia, the bottoms of the crura were torn. In the patient reoperated 3 days postoperatively, the procedure was easily performed, the postoperative course was uneventful and the patient was symptom-free after a follow-up of 20 months. In the patient reoperated 6 days postoperatively, the upper part of the stomach had moved into the left pleural cavity, the procedure was difficult due to inflammation and thickening of the gastric wall, and the postoperative course was uneventful, but reflux recurred 18 months later.

CONCLUSION

When severe dysphagia or paraesophageal hernia occurs during the immediate postoperative course of laparoscopic partial posterior fundoplication, reoperation, possibly by laparoscopy, identifies and cures the technical defects. Based on our experience, we suggest that surgical cure of paraesophageal hernia is easier when performed during the immediate postoperative period.

The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery

OBJECTIVE

To discuss the pathophysiology and incidence of the short esophagus, to review the history of treatment, and to describe diagnosis and possible treatments in the era of laparoscopic surgery.

SUMMARY BACKGROUND DATA

The entity of the short esophagus in antireflux surgery is seldom discussed in the laparoscopic literature, despite its emphasis in the open literature for more than 40 years. This may imply that many laparoscopic patients with short esophagi are unrecognized and perhaps treated inappropriately. Intrinsic shortening of the esophagus most commonly occurs in patients with chronic gastroesophageal reflux disease that involves recurring cycles of inflammation and healing, with subsequent fibrosis. The actual incidence of the short esophagus is estimated to be approximately 10% of patients undergoing antireflux surgery. Of this group, 7% can be appropriately managed with extensive mediastinal mobilization of the esophagus to achieve the required esophageal length. The remaining 3% require an aggressive surgical approach, including the use of gastroplasty procedures, to create an adequate length of intraabdominal esophagus to perform a wrap. Several effective minimally invasive techniques have been developed to deal with the short esophagus.

CONCLUSIONS

Because a short esophagus is uncommon, there is a natural concern that many surgeons will not perform enough antireflux procedures to become familiar with its diagnosis and management. A complete understanding of the short esophagus and methods for surgical correction are critical to avoid "slipped" wraps and mediastinal herniation and to achieve the best patient outcome.

Laparoscopic esophageal surgery

In its 9-year history, laparoscopic esophageal surgery has become second only to gallbladder surgery in the frequency of minimally invasive procedures performed in routine surgical practice. Laparoscopic fundoplication has assumed a central role in the surgical treatment of gastroesophageal reflux. Laparoscopic myotomy has emerged as the optimal form of therapy for achalasia, and staging laparoscopy has been identified as an important adjunct to the preoperative evaluation of esophageal and gastroesophageal junction carcinoma. Laparoscopic paraesophageal hernia repair and remedial laparoscopic antireflux surgery currently are gaining acceptance. Laparoscopic gastroplasty, esophagectomy, and diverticulectomy are undergoing clinical trials, and their roles remain to be defined.

Minimally invasive approaches to antireflux surgery

Gastroesophageal reflux disease is one of the most common disorders affecting western civilization. Historically, surgical antireflux therapy was reserved for patients who had failed medical therapy, typically in the presence of refractory ulcers or difficult-to-manage strictures. More recently, with improvements in acid control, these acid-pepsin-related complications of reflux have been replaced by the malignant complications of reflux disease, with emphasis now on total control of reflux. Recent developments in surgical technique and the demonstrated effectiveness of a variety of minimally invasive treatment options have changed our approach to these patients. This article summarizes the recommended diagnostic evaluation of patients with reflux symptoms and the current indications for antireflux surgery. The techniques of commonly performed minimally invasive antireflux procedures are described along with a review of the results to be expected. Future prospects for improving the management of reflux are discussed; these include recently described nonsurgical methods for restoring competency to the lower esophageal sphincter.

Liver hematoma after laparoscopic nissen fundoplication: a case report and review of retraction injuries

Laparoscopic fundoplication is a safe and effective alternative to long-term medical therapy in select patients with gastroesophageal reflux disease. Among the technical challenges of laparoscopic fundoplication, retraction of the left lobe of liver can cause significant morbidity. Intraoperative complications from retraction injuries have been reported in the literature, but postoperative complications arising from liver retraction have not been published. The authors present a case of a symptomatic liver hematoma requiring hospital readmission for diagnosis and pain control and a review of retraction injuries.

Complicações do tratamento laparoscópico da doença do refluxo gastroesofágico: experiência com 600 casos

O objetivo do presente estudo é apresentar as complicações que ocorreram em seiscentos pacientes consecutivos com doença do refluxo gastroesofágico submetidos à fundoplicatura laparoscópica. O procedimento de Nissen-Rosetti (fundoplicatura de 360°) foi realizado em 587 pacientes (97,8%) e o de Toupet (fundoplicatura de 270°) em 13 (2,2%). Oitenta e um pacientes também foram submetidos à colecistectomia no mesmo ato operatório, e um a diverticulectomia faringoesofágica cervical com miotomia cricofaringeana. Trinta e nove pacientes tinham operação prévia no abdome superior. O período de internação hospitalar variou de 12 horas a 23 dias, com média de 1,2 dias. A via de acesso foi convertida em laparotomia em dez pacientes (1,7%). A principal causa de conversão foi a presença de aderências. A complicação intra- operatória mais freqüente foi pneumotórax, que foi observado em oito pacientes. Todos os pneumotóraces ocorreram nos cem primeiros casos. Cinco pacientes apresentaram hemorragia significante, sendo que dois deles necessitaram laparotomia para controle do sangramento. Úlcera gástrica foi diagnosticada em sete pacientes. Um paciente etilista morreu de pancreatite aguda e outro de síndrome de disfunção de múltiplos órgãos e sistemas conseqüente à perfuração gástrica. Outras complicações importantes foram: dois abscessos intra-abdominais, uma perfuração esofágica, uma sepse secundária à perfuração gástrica, um choque hemorrágico e uma obstrução gástrica secundária à herniação da fundoplicatura. Concluímos que a taxa de complicações da fundoplicatura laparoscópica é baixa e diminui significativamente com a experiência do cirurgião.

Anatomic fundoplication failure after laparoscopic antireflux surgery

OBJECTIVE

Anatomic fundoplication failure occurs after antireflux surgery and may be more common in the learning curve of laparoscopic antireflux surgery (LARS). The authors' aims were to assess the incidence, presentation, precipitating factors, and management of anatomic fundoplication failures after LARS.

SUMMARY BACKGROUND DATA

The advent of LARS has increased the frequency with which antireflux surgery is performed for the treatment of gastroesophageal reflux disease. Postoperative symptoms frequently occur and may result from physiologic abnormalities or anatomic failure of the fundoplication (e.g., displacement or disruption). Few data exist on the potential causes or best treatment of anatomic fundoplication failures.

METHOD

LARS was performed in 290 patients by one of the authors over a 6-year period. In the first 53 patients (group 1), the short gastric vessels were divided on a selective basis and the diaphragmatic crura were closed only when large hiatal hernias were present. In the subsequent 237 patients (group 2), the crura were always approximated posterior to the short gastric vessels and full fundic mobilization was performed. Clinical postoperative evaluation was performed on a regular basis, with detailed tests of anatomy and physiology when untoward symptoms developed. Postoperative foregut symptoms were reported by 26% of the patients, of whom 73% were found to have an intact fundoplication. In 7% of the entire group, anatomic failure of the fundoplication was demonstrated, with the majority exhibiting intrathoracic migration of the wrap with or without disruption of the fundoplication. New-onset postoperative epigastric or substernal chest pain frequently heralded fundoplication failure. Factors correlated with the development of anatomic fundoplication failure included presence in group 1, early postoperative vomiting, other diaphragm "stressors," and large hiatal hernias. Repeat operation has been performed in 8 of the 20 patients (40%), with 5 patients successfully treated using laparoscopic techniques.

CONCLUSIONS

Anatomic fundoplication failure occurred in 7% of patients undergoing LARS, with the majority occurring in patients who underwent surgery during the learning curve. Anatomic failure is associated with technical shortcomings, large hiatal hernias, and early postoperative vomiting. Full esophageal mobilization and meticulous closure of the diaphragmatic crura posterior to the esophagus should minimize anatomic functional failure after LARS.

Laparoscopic reoperation following failed antireflux surgery

BACKGROUND

The aim was to determine the feasibility of laparoscopic revision surgery following previous open and laparoscopic antireflux operations.

METHODS

The outcome was determined for 27 patients (14 men, 13 women) who had undergone attempted laparoscopic revision between 3 months and 25 years after a previous antireflux operation. Median follow-up was 12 (range 3-48) months.

RESULTS

Thirteen patients had previously had an open antireflux procedure (Nissen fundoplication, seven; transthoracic anatomical repair, five; Belsey procedure, one) and 14 a laparoscopic procedure (Nissen, 12; anterior partial fundoplication, two). The indications for revision were: recurrent reflux, 15; paraoesophageal hiatus hernia, six; troublesome dysphagia, six. Fifteen procedures comprised construction of a new Nissen fundoplication, six conversion from a Nissen to a partial wrap, three repair of a paraoesophageal hernia and three widening of the oesophageal hiatus. Revision was successfully completed laparoscopically in 12 patients following a previous laparoscopic procedure and in nine following a previous open operation. Median operating time was 105 min after previous open surgery and 80 min after laparoscopic surgery. No perioperative complications occurred in either group and a good outcome was achieved in 25 of the 27 patients.

CONCLUSION

Laparoscopic reoperative antireflux surgery is feasible. Reoperation is likely to be more difficult following failure of an open procedure than a laparoscopic one.

Paraesophageal herniation as a complication following laparoscopic antireflux surgery

Paraesophageal herniation of the stomach is a rare complication following laparoscopic Nissen fundoplication. We retrospectively reviewed our experience with 720 patients undergoing laparoscopic Nissen fundoplications. Seven patients were found to have postoperative paraesophageal hernias requiring reoperation. The clinical presentation, diagnostic workup, operative treatment, and outcome were evaluated. There were no deaths or procedure-related complications. Clinical presentation was recurrent dysphagia in four, nonspecific abdominal symptoms in one, and acute abdomen in one. One additional patient was asymptomatic. Preoperatively the correct diagnosis was able to be confirmed in four of six patients by barium esophagogram. Four patients underwent successful laparoscopic repair. Two patients had a thoracotomy including one conversion from laparoscopy to thoracotomy. One patient had a lap-arotomy to reduce an intrathoracic gastric volvulus. At a mean follow-up of 2.5 months no patient had further complications. Paraesophageal herniation is a rare complication following laparoscopic Nissen fundoplication and a definitive diagnosis is often difficult to establish. Early dysphagia after surgery should alert the surgeon to this complication. Redo laparoscopic surgery is feasible but an open procedure may be necessary.

Diaphragmatic herniation following oesophagectomy

BACKGROUND

Intrathoracic herniation of abdominal viscera is a potentially life-threatening condition, especially when diagnosis is delayed. The aim of this study was to estimate its incidence following oesophageal resection and to define contributing factors that might influence its occurrence.

METHODS

All radiographic studies of the chest that were made during follow-up in a series of 218 patients who underwent oesophagectomy between 1993 and 1997 were reviewed.

RESULTS

Herniation of bowel alongside the oesophageal substitute was detected in nine patients (4 per cent). Four hernias occurred within the first week after operation and five were detected at late follow-up. Surgical treatment was indicated in six patients. Analysis of predisposing factors revealed that extended incision and partial resection of the diaphragm were associated with an increased risk of postoperative hernia formation (four of 29 following extended enlargement versus five of 189 after routine opening of the oesophageal hiatus; P = 0.02).

CONCLUSION

Diaphragmatic herniation was found in 4 per cent of patients after oesophagectomy. After extended iatrogenic disruption of the normal hiatal anatomy, narrowing of the diaphragmatic opening may be indicated to avoid postoperative herniation of bowel into the chest. Awareness of its possible occurrence may help prevent the development of intestinal obstruction and strangulation.

Antireflux surgery in the laparoscopic era

BACKGROUND

The recent development of laparoscopic techniques for fundoplication has created renewed interest in surgery for gastro-oesophageal reflux disease, leading to reports of large clinical series from many centres. However, controversy remains about technical aspects of laparoscopic antireflux surgery, with no consensus yet reached about a standard operative technique. It is important, therefore, to reassess critically the results of laparoscopic surgery for reflux disease, so that its current status can be determined.

METHODS

Published outcome studies for laparoscopic antireflux surgery, as well as selected studies from the era of open antireflux surgery, were reviewed to assess outcomes.

RESULTS

The results of case series for laparoscopic antireflux surgery with short- and medium-term follow-up, as well as the early results of randomized trials, confirm that this approach reduces the early overall morbidity of surgery for reflux disease. However, certain complications may be more common, for instance paraoesophageal hiatus herniation, pneumothorax and oesophageal perforation, requiring surgeons to use specific strategies which can help to avoid these problems. Published studies and trials do not support the routine or selective application of a posterior partial fundoplication technique or routine division of the short gastric vessels during Nissen fundoplication.

CONCLUSION

At present, a short loose Nissen fundoplication performed laparoscopically, with or without division of the short gastric vessels, is an appropriate surgical approach for gastro-oesophageal reflux disease. However, long-term outcomes following laparoscopic antireflux surgery will not be available for some years, and must be awaited before the final status of the various laparoscopic techniques can be confirmed.

Laparoscopic redo Nissen fundoplication

Nine patients underwent redo laparoscopic Nissen fundoplication because of failed primary laparoscopic antireflux procedure. Symptoms prior to reoperation included heartburn (n = 5), dysphagia (n = 2), dysphagia and heartburn (n = 1), and early satiety and epigastric pain (n = 1). Endoscopic and radiologic findings prior to reoperation included esophagitis (n = 6), reflux (n = 6), stenosis (n = 2), and hiatal hernia (n = 1). Findings at reoperation included fundoplication positioned on the stomach (n = 5); a disrupted cruroplasty (n = 1); gastric volvulus (n = 1); and an excessively tight wrap (n = 1) or cruroplasty (n = 1). Reconstruction of the fundoplication was performed according to accepted principles for this procedure. All patients were discharged within 2 days after the redo procedure. Follow-up time is 4-14 months. Preoperative symptoms were relieved in all patients and all antireflux medication have been discontinued. Routine postoperative esophagram and endoscopy demonstrated intact repair and without gastroesophageal reflux or stenosis. Reoperative laparoscopic Nissen fundoplication is feasible and effective.