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

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF).

SUMMARY OF BACKGROUND DATA

Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair.

METHODS

A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%).

CONCLUSIONS

LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

Laparoscopic Heller myotomy and Dor fundoplication in the same day surgery setting with a trained team and an enhanced recovery protocol

Background

The length of stay after Heller myotomy is 1–5 days. The aim was to report feasibility of the procedure as same day surgery (SDS).

Methods

Three steps of Enhanced Recovery After Surgery protocol: preoperatively, clear liquid diet for 24 hours, in preoperative area: antiemetics as dermal patch/IV form, 2: Intraoperatively, intubation in semi upright position, IV analgesics and antiemetics. 3: Postoperatively, clear liquid diet and discharge instructions. Patients were followed using a phone questionnaire. Values are median (interquartile range).

Results

Fifty-seven patients, 32 M (56%)/25F (44%), age 48 (35–59). First 45 were inpatient with LOS of 1 day. Last 12 were planned as same day surgery, 1/12 was discharged on POD#2, 11/12 (92%) were performed as same day surgery. The duration of operation: 139.5 min (114–163) inpatient: vs 123 (107–139) same day surgery, P < .01. Questionnaires were obtained in 78% inpatient at 40 months (25.6–67) vs 82% same day surgery at 8 (4–12). All were satisfied with the operation with no difference between the 2 groups.

Conclusion

Heller myotomy can be planned as same day surgery and performed successfully in majority of patients with a trained team and an Enhanced Recovery After Surgery protocol focused on prevention of nausea, and pain control in perioperative period.

Patient-related risk factors associated with symptomatic recurrence requiring reoperation in laparoscopic hiatal hernia repair

Background

Recurrent hiatal hernia remains a challenge.

Methods

For initial repairs at our center: patients with 1 repair were compared to those who required reoperation for symptomatic recurrence. Subsequently, patients who had 1 repair at our center were compared to all patients who required reoperation (including initial repair at another center).

Results

There were 401 repairs: 308 primary repairs at our center and 93 reoperations, 287/308 (93%) required 1 repair and 21/308 (7%) required reoperation. Comparing 1 repair versus 21 reoperations, risk factors were abdominoplasty odds ratio = 32.0 (4.1-250.6), P < .001, postoperative lifting/vomiting odds ratio = 11.6 (3.2-42.1), P < .0002, tubal ligation odds ratio = 4.9 (1.1-22.6), P < .04 and height < 160 cm odds ratio = 3.9 (1.1-13.3) P < 0.03. Comparing 287 with 1 repair versus all 93 reoperations, risk factors were post-operative vomiting odds ratio = 22.7 (2.3-218.0), P < .007, abdominoplasty odds ratio = 5.6 (1.0-31.4), P < .0495, post-operative lifting odds ratio = 5.4 (2.2-12.9), P < .0002, age < 52 odds ratio = 3.6 (1.8-7.3), P < .0003, tubal ligation odds ratio = 3.2 (1.2-8.7), P < 0.019 and height < 160 cm odds ratio = 3.0 (1.5-6.1), P < 0.003.

Conclusions

Younger age, shorter stature, heavy lifting or vomiting after surgery, abdominoplasty and tubal ligation are risk factors associated with symptomatic recurrence requiring reoperation.

Salvage Options for Fundoplication Failure

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients.

RECENT FINDINGS

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.

A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication?

BACKGROUND

Nearly 20% of patients who undergo hiatal hernia (HH) repair and anti-reflux surgery (ARS) report recurrent HH at long-term follow-up and may be candidates for redo surgery. Current literature on redo-ARS has limitations due to small sample sizes or single center experiences. This type of redo surgery is challenging due to rare but severe complications. Furthermore, the optimal technique for redo-ARS remains debatable. The purpose of the current multicenter study was to review the outcomes of redo-fundoplication and to identify the best ARS repair technique for recurrent HH and gastroesophageal reflux disease (GERD).

METHODS

Data on 975 consecutive patients undergoing hiatal hernia and GERD repair were retrospectively collected in five European high-volume centers. Patient data included demographics, BMI, techniques of the first and redo surgeries (mesh/type of ARS), perioperative morbidity, perioperative complications, duration of hospitalization, time to recurrence, and follow-up. We analyzed the independent risk factors associated with recurrent symptoms and complications during the last ARS. Statistical analysis was performed using GraphPad Prism^® and R software^®.

RESULTS

Seventy-three (7.49%) patients underwent redo-ARS during the last decade; 71 (98%) of the surgeries were performed using a minimally invasive approach. Forty-two (57.5%) had conversion from Nissen to Toupet. In 17 (23.3%) patients, the initial Nissen fundoplication was conserved. The initial Toupet fundoplication was conserved in 9 (12.3%) patients, and 5 (6.9%) had conversion of Toupet to Nissen. Out of the 73 patients, 10 (13%) underwent more than one redo-ARS. At 8.5 (1-107) months of follow-up, patients who underwent reoperation with Toupet ARS were less symptomatic during the postoperative period compared to those who underwent Nissen fundoplication (p = 0.005, OR 0.038). Patients undergoing mesh repair during the redo-fundoplication (21%) were less symptomatic during the postoperative period (p = 0.020, OR 0.010). The overall rate of complications (Clavien-Dindo classification) after redo surgery was 11%. Multivariate analysis showed that the open approach (p = 0.036, OR 1.721), drain placement (p = 0.0388, OR 9.308), recurrence of dysphagia (p = 0.049, OR 8.411), and patient age (p = 0.0619, OR 1.111) were independent risk factors for complications during the last ARS.

CONCLUSIONS

Failure of ARS rarely occurs in the hands of experienced surgeons. Redo-ARS is feasible using a minimally invasive approach. According to our study, in terms of recurrence of symptoms, Toupet fundoplication is a superior ARS technique compared to Nissen for redo-fundoplication. Therefore, Toupet fundoplication should be considered in redo interventions for patients who initially underwent ARS with Nissen fundoplication. Furthermore, mesh repair in reoperations has a positive impact on reducing the recurrence of symptoms postoperatively.

Management of failure after surgery for gastro-esophageal reflux disease

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.

Primary and Redo Antireflux Surgery: Outcomes and Lessons Learned

INTRODUCTION

Some patients require one or more reoperative interventions after undergoing primary antireflux surgery (ARS). We compared outcomes after primary and reoperative ARS.

METHODS

We 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.

RESULTS

In 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).

CONCLUSIONS

Complications and patient-reported outcomes worsen with each reoperative ARS.