Long-term results after reoperation for failed antireflux procedures

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.

Reoperative antireflux surgery

Patient satisfaction with primary antireflux surgery is high, but a small percentage of patients experience recurrent reflux and dysphagia, requiring reoperation. The major anatomic causes of failed fundoplication are slipped fundoplication, failure to identify a short esophagus, and problems with the wrap. Minimally invasive surgery has become more common for these procedures. Options for surgery include redo fundoplication with hiatal hernia repair if needed, conversion to Roux-en-Y anatomy, or, as a last resort, esophagectomy. Conversion to Roux-en-Y anatomy has a high rate of success, making this approach an important option in the properly selected patient.

Roux-en-Y near esophagojejunostomy for failed antireflux operations: outcomes in more than 100 patients

BACKGROUND

Intractable gastroesophageal reflux disease (GERD) after antireflux operations presents a challenge-particularly in obese patients and patients with esophageal dysmotility-and increases the complexity of the redo operation. This study evaluated the results of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of recurrent GERD after antireflux operations.

METHODS

We conducted a retrospective review of overweight patients with intractable GERD who underwent RNYNEJ for failed antireflux operations. We evaluated perioperative outcomes, dysphagia (ranging from 1 = no dysphagia to 5 = unable to swallow saliva), and quality of life (QOL) (assessed using the GERD health-related quality-of-life instrument (HRQOL).

RESULTS

Over a 12-year period, 105 patients with body mass index (BMI) greater than 25 underwent RNYNEJ for failed antireflux operations. Most were obese (BMI > 30; 82 patients [78%]); esophageal dysmotility was demonstrated in more than one-third of patients. Forty-eight (46%) patients had multiple antireflux operations before RNYNEJ, and 27 patients had undergone a previous Collis gastroplasty. There was no perioperative mortality. Major complications, including anastomotic leak requiring surgical intervention (n = 3 [2.9%]), were noted in 25 patients (24%).The median length of stay was 6 days. During follow-up (mean, 23.39 months), median BMI decreased from 35 to 27.6 (p < 0.0001), and the mean dysphagia score decreased from 2.9 to 1.5 (p < 0.0001). The median GERD HRQOL score, assessed in a subset of patients, was 9 (classified as excellent).

CONCLUSIONS

RNYNEJ for persistent GERD after antireflux operations in appropriately selected patients can be performed safely with good results in experienced centers. RNYNEJ should be considered an important option for the treatment of intractable recurrent symptoms after antireflux operations, particularly in obese patients.

Does BMI predict recurrence or complications after reoperative reflux surgery? Review of a single center's experience and a comparison of outcomes

INTRODUCTION

Obese patients who fail primary surgical management of gastroesophageal reflux present a significant challenge. We reviewed our outcomes with reoperative reflux surgery in obese (body mass index (BMI) >30) and nonobese patients to identify predictors of failure and complications and evaluate whether reoperative fundoplication is the ideal solution for obese patients.

METHODS

We conducted a retrospective review of consecutive patients undergoing reoperation for failed anti-reflux surgery between 1994 and 2013. Medical record review identified preoperative, intraoperative, and postoperative characteristics. Short- and long-term outcomes for obese and nonobese patients were compared using descriptive statistics and logistic regression.

RESULTS

One hundred and nine interventions were identified in 95 patients. Clinical characteristics were similar between obese and nonobese patients. Eighty-eight (83.8%) patients underwent laparoscopic repair, 87 (79.8%) of whom had a Nissen fundoplication. Obese patients were more likely to fail via a slipped wrap (64.7 vs. 40.0%; p = 0.02). No differences were seen in short- or long-term symptomatic relief or major complications. In bivariate analysis, short-term outcomes were predicted by preoperative albumin <3.5 mg/dL (odds ratio (OR), 0.27 (confidence interval (CI), 0.08-0.96); p = 0.04) and laparoscopic conversion (OR, 0.19 (CI, 0.04-1.03); p = 0.05). Laparoscopic conversion was associated with major complications (OR, 7.33 (CI, 1.33-40.55); p = 0.02). BMI was a significant predictor for long-term outcome (p = 0.03) as a continuous variable in sensitivity analyses.

CONCLUSIONS

Obese patients with recurrence after failed anti-reflux operation may be safely treated with a repeat operation. Our data indicate no difference in outcomes for patients with BMI >30, underscoring the importance of preoperative discussion as to the best approach: reoperative fundoplication or a gastric bypass.

Laparoscopic repair for failed antireflux procedures

BACKGROUND

Minimally invasive procedures have become common, and more reoperations for failed antireflux procedures are performed laparoscopically. We wanted to study the outcomes of laparoscopic reoperations for reflux.

METHODS

Medical records of all patients who underwent reoperation without esophageal resection after previous antireflux procedures between January 2000 and October 2012 were reviewed.

RESULTS

Seventy-five patients were included in this report: 56 (77%) women and 19 (23%) men. Median age was 58 years. The previous operation was laparoscopic antireflux procedures in 65 (87%) patients. The median interval between the last antireflux procedure and laparoscopic reoperation was 42 months. The median body mass index (BMI) was 28.7. All patients were symptomatic. Intraoperative findings included recurrent hiatal hernia in 47 (63%) patients, incompetent fundoplication in 14 (19%) patients, tight fundoplication in 8 (11%) patients, and tight crura in 2 (3%) patients. Laparoscopic Nissen fundoplication was performed in 57 (76%) patients, partial posterior fundoplication was performed in 12 (16%) patients, partial anterior fundoplication was performed in 3 (4%) patients, removal of crural stitches was performed in 2 patients, and a combination of partial posterior fundoplication and removal of crural stiches was performed in 1 patient. Complications occurred in 13 (15%) patients. Improvement in symptoms was observed in 70 (93%) patients in early postoperative follow-up and in 59 (78%) patients in long-term follow-up. Functional results were classified as excellent in 59 (78%) patients, good in 6 (7%) patients, fair in 7 (8%) patients, and poor in 3 (4%) patients.

CONCLUSIONS

Laparoscopic reoperation for failed antireflux operations is a complex procedure, but it is safe and effective in selected patients. Reoperation after a failed antireflux repair results in excellent or good functional status in a majority of patients, but these results may deteriorate over time.

Long-term outcomes of reintervention for failed fundoplication: redo fundoplication versus Roux-en-Y reconstruction

BACKGROUND

Redo fundoplication (RF) is the mainstay of treatment for failed fundoplication. A subset of patients with failed fundoplication requires Roux-en-Y reconstruction (RNY) for symptom relief. The aim of this study was to compare the long-term subjective outcomes between RF and RNY in patients with failed fundoplication.

METHODS

After Institutional Board Review approval, retrospective review of a prospective database identified 119 RF (mean = 54.1 years, 78 women) and 64 RNY (mean = 54.8 years, 35 women) patients who underwent reoperative surgery between December 2003 and September 2009. Data variables analyzed included demographics, esophageal manometry, 24-h pH study, type of procedure, perioperative findings, complications, pre- and postoperative symptom (heartburn, regurgitation, dysphagia, and chest pain) scores (scale 0-3), and patient satisfaction score (scale 1-10). Patients with grade 2 and 3 scores were considered to have significant symptoms.

RESULTS

Patients who underwent RNY had a significantly higher body mass index, higher mean number of risk factors, and higher preoperative severity of heartburn and regurgitation compared to the RF group. Of the 183 patients, long-term (>3 years) follow-up was available for 132 (89 RF and 43 RNY) patients. Symptom severity significantly improved after both procedures, with the exception of dysphagia in the RNY group. Overall, there was no significant difference in patients' satisfaction between the RF and RNY groups. In subset analysis, patients with morbid obesity, esophageal dysmotility, or ≥4 risk factors have better satisfaction with RNY compared to RF (p = 0.027, 0.031, and 0.045, respectively).

CONCLUSIONS

RF and RNY have equally good patient satisfaction at 3 years follow-up. RNY may have improved outcomes in patients who are morbid obese, have esophageal dysmotility, or have four or more risk factors.

Transthoracic repair of slipped Nissen fundoplications: technique and results

BACKGROUND

Laparoscopic Nissen fundoplication is a common operation performed for reflux disease, generally with good results. A small percentage of patients experience transthoracic migration of the wrap, causing recurrent symptoms and eventually requiring transthoracic repair.

METHODS

A retrospective chart review was performed for all patients who underwent a transthoracic repair of a slipped Nissen fundoplication at our institution from 2006 to 2010. Data included demographics, previous antireflux operations, symptoms at presentation, findings at operation, and overall outcome.

RESULTS

Sixteen patients with a mean age of 61 years (range, 51-76 years) were identified who fit inclusion criteria. The most common presenting symptom was pain. Intraoperative findings included hiatal breakdown in all patients, shortened esophagus in 10 (62%) patients, and foreign body/mesh in 4 (25%) patients. Nine (56%) patients underwent a Collis gastroplasty along with a Nissen fundoplication. Nissen fundoplication alone was performed in 6 (38%) patients and a Belsey fundoplication with a Collis gastroplasty was performed in 1 (6%) patient. Minor complications occurred in 4 (25%) patients and major complications were seen in 2 (13%) patients. The median length of stay was 9 days (range, 6-30 days). There were no postoperative deaths. Overall, 12 (75%) of the patients were judged to have a good outcome, 3 (19%) a fair outcome, and 1 (6%) a poor outcome over a median 9-month follow-up.

CONCLUSIONS

Transthoracic repair in patients who have had transthoracic migration of a previous Nissen fundoplication has acceptable surgical outcome and affords symptomatic relief to the majority 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.

Reoperative antireflux surgery for failed fundoplication: an analysis of outcomes in 275 patients

BACKGROUND

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.

METHODS

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.

RESULTS

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%.

CONCLUSIONS

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.

Long-term results after laparoscopic reoperation for failed antireflux procedures

BACKGROUND

Surgery for failed antireflux procedures is technically more demanding than primary fundoplication. The success rate does not equal that of the primary procedures. This retrospective analysis aimed to assess long-term subjective and objective outcomes in patients who underwent laparoscopic surgery for fundoplication failure.

METHODS

Objective and subjective outcomes were assessed by radiological and endoscopic methods, symptom questionnaire and quality-of-life index at a minimum follow-up of 12 (mean 75·8) months.

RESULTS

The study included 129 consecutive patients who had laparoscopic redo surgery after fundoplication had failed. The most frequent patterns of failure were hiatal herniation (50 patients) and slippage (45). Resolution of the symptoms that led to redo surgery was achieved in 27 of 37 and 11 of 16 patients operated for recurrence and for dysphagia respectively. Objective failure was demonstrated in 16 of 39 patients with herniation and six of 22 with slippage. Seven patients underwent an additional surgical procedure.

CONCLUSION

Long-term assessment of objective and subjective results after laparoscopic repair for failed fundoplication revealed a high failure rate that increased with the length of follow-up. Unexpected and untreated oesophageal shortening may be responsible for this failure rate.

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.

Reoperative antireflux surgery for dysphagia

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Outcomes after esophagectomy in patients with prior antireflux or hiatal hernia surgery

BACKGROUND

Esophagectomy is indicated occasionally for the treatment of patients with refractory gastroesophageal reflux disease (GERD) or recurrent hiatus hernia. The purpose of this study was to evaluate the impact of previous gastroesophageal operations on outcomes after esophagectomy for recurrent GERD or hiatus hernia.

METHODS

Using a prospectively accumulated database, a retrospective review was performed to identify patients undergoing esophagectomy for complicated GERD or hiatus hernia. Mortality, perioperative and functional outcomes, and need for reoperation were evaluated, assessing esophagectomy patients who had undergone prior operations for GERD or hiatus hernia.

RESULTS

Of 258 patients with GERD or hiatus hernia undergoing esophagectomy, 104 had undergone a previous operation, with a median interval to esophagectomy of 28 months. Transhiatal resection was accomplished in fewer patients undergoing reoperation (87 of 104 versus 151 of 154; p<0.005). A gastric conduit was used as an esophageal replacement in fewer patients with previous operation(s) (89 of 104 versus 150 of 154; p<0.005). Esophagectomy patients with a history of prior gastroesophageal surgery, as compared with those without, sustained more blood loss and were more likely to require reoperation, and fewer reported good to excellent swallowing function (p<0.05). There was no difference in the occurrence of anastomotic leak.

CONCLUSIONS

Esophagectomy in patients who have undergone prior operations for either GERD or hiatus hernia can be accomplished without thoracotomy and with satisfactory intermediate-term quality of life. Such patients should be evaluated and prepared for the use of alternative conduits should the remobilized stomach prove to be an unsatisfactory esophageal substitute at the time of esophagectomy.

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.

Predictors of symptomatic and objective outcomes after surgical reintervention for failed antireflux surgery

BACKGROUND

Recurrent gastro-oesophageal reflux disease (GORD) and troublesome dysphagia after primary antireflux surgery are treated successfully by reoperation in 70 per cent of patients. Identifying predictors of outcome could allow selection of patients likely to benefit from further surgery. The aim was to identify such predictors in patients reoperated on for recurrent GORD or troublesome dysphagia.

METHODS

Between 1994 and 2005, 83 patients (mean(s.d.) age 47.2(14.4) years; 47 men) with recurrent GORD and 47 (aged 50.7(13.4) years; 18 men) with troublesome dysphagia had further surgery. The predictive values of demographic, anatomical and manometric variables, and 24-h pH monitoring were analysed with respect to symptomatic and objective outcomes in each group.

RESULTS

None of the factors included in a multivariable analysis predicted outcome after surgery for recurrent GORD. Independent predictors of symptomatic outcome after reoperation for dysphagia were amplitude of distal oesophageal contractions (odds ratio (OR) 1.613 (95 per cent confidence interval (c.i.) 1.087 to 2.393); P = 0.017), intrathoracic wrap migration (OR 0.077 (0.003 to 1.755); P = 0.108) and an abdominal approach (OR 0.012 (0.001 to 0.337); P = 0.009).

CONCLUSION

Low-amplitude distal oesophageal contractions, intrathoracic wrap migration and an abdominal approach were significant predictors of an unsuccessful symptomatic outcome after reoperation for troublesome dysphagia.

Roux-en-Y near esophagojejunostomy for intractable gastroesophageal reflux after antireflux surgery

BACKGROUND

Intractable gastroesophageal reflux disease (GERD) after prior antireflux operation presents a difficult challenge. Our objective was to investigate the role of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of intractable reflux symptoms after prior antireflux surgery.

METHODS

Between June 2000 and October 2005, 25 patients with GERD after antireflux surgery underwent RNYNEJ. The endpoints evaluated were improvement in GERD symptoms using the GERD-Health Related Quality of Life (HRQL) scale, overall patient satisfaction, overall patient weight loss, and improvement of comorbid conditions.

RESULTS

There were 4 men and 21 women (mean age 51 years; range, 35 to 74). Seventy two percent had a body mass index (BMI) greater than 30. Forty-four percent had more than one antireflux surgery and 40% had a previous Collis gastroplasty. The perioperative mortality was 0%. Six patients (24%) developed major postoperative complications, including anastomotic leak (n = 2) and Roux-limb obstruction (n = 1). The median length of stay was 6 days. Eighty percent of the patients reported satisfaction at mean follow-up time of 16.5 months. Their BMI reduced from 35.8 to 27.7 (p < 0.001). Seventy three percent of comorbid conditions were improved and the GERD HRQL score improved from 29.9 to 7.3 (p < 0.001).

CONCLUSIONS

The RNYNEJ for persistent GERD after prior antireflux surgery is technically challenging with significant morbidity. However, the majority of the patients reported satisfaction with significant improvement in symptoms. Many patients had associated benefits of weight loss and improvement in comorbid conditions. Roux-en-Y near esophagojejunostomy should be considered as an important option for the treatment of intractable GERD after prior antireflux surgery, particularly in the obese.

Medium- and long-term outcome of laparoscopic redo fundoplication

BACKGROUND

For a small subset of patients, laparoscopic fundoplication fails, typically resulting in recurrent reflux or severe dysphagia. Although redo fundoplications can be performed laparoscopically, few studies have examined their long-term efficacy.

METHODS

Using a prospectively maintained database, the authors identified and contacted 41 patients who had undergone redo laparoscopic fundoplications at the University of Washington between 1996 and 2001. The median follow-up period was 50 months (range, 20-95 months). Current symptoms were compared with those acquired and entered into the authors' database preoperatively. Patients also were asked to return for esophageal manometry and pH testing.

RESULTS

All redo fundoplications were performed laparoscopically. There were no conversions. The most common indication for redo fundoplication was recurrent reflux. The most common anatomic abnormality was a herniated wrap. Heartburn improved in 61%, regurgitation in 69%, and dysphagia in 74% of the patients. Complete resolution of these symptoms was achieved, respectively, in 45%, 41% and 38% of these same patients. Overall, 68% of the patients rated the success of the procedure as either "excellent" or "good," and 78% said they were happy they chose to have it. For those who underwent reoperation for gastroesophageal reflux disease, distal esophageal acid exposure according to 24-h pH monitoring decreased after redo fundoplication from 15.7% +/- 18.1% to 3.4% +/- 3.6% (p = 0.041).

CONCLUSION

Although not as successful as primary fundoplication, a majority of patients can expect durable improvement in their symptoms with a laparoscopic redo fundoplication.

Failed antireflux surgery: results after reoperation

BACKGROUND

Since laparoscopy has become a common surgical approach for antireflux surgery, little is known regarding reoperation for failed antireflux surgery.

METHODS

Records of all patients who underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease or hiatal hernia between July 1, 1995 and April 1, 2004 were reviewed. There were 126 patients. Two patients declined research participation. The remaining 124 patients (71 women and 53 men) formed the basis for this study. Median age was 53 years (range, 19 to 83 years). The initial operation was a laparoscopic antireflux procedure in 76 patients (61.3%) and an open repair in 48 (38.7%). A single previous operation had been done in 100 patients, two operations in 20, and three operations in 4. The median interval between the most recent reoperation and the previous operation was 28 months. All patients were symptomatic. The surgical approach was a thoracotomy in 83 patients, laparotomy in 36, laparoscopy in 4, and thoracoabdominal in 1. A Nissen fundoplication was performed in 86 patients (69.4%), Belsey fundoplication in 31(25.0%), and others in 7.

RESULTS

There were no operative deaths. Complications occurred in 27 patients (21.7%). Median hospitalization was 6 days (range, 5 to 58 days). Follow-up ranged from 10 days to 10 years (median, 9.7 months). Improvement was observed in 114 patients (91.9%). Functional results were classified as excellent in 69 patients (55.6%), good in 19 (15.4%), fair in 26 (20.9%), and poor in 10 (8.1%). No single operative approach was functionally superior.

CONCLUSIONS

We conclude that reoperation for failed antireflux surgery is safe and effective. Results of reoperation were not affected by the type of reoperation or whether the previous approach was laparoscopic or open.

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center. Data on patients undergoing antireflux surgery in our unit has been prospectively collected and includes more than 600 primary laparoscopic antireflux operations since 1993. Laparoscopic reoperations have been performed between 1996 and 2005 for patients suffering recurrent reflux, dysphagia or severe gas bloat symptomatic despite medical treatment. All patients underwent preoperative barium studies and endoscopy with selective manometry and pH studies. Symptomatic outcomes were evaluated at 6 weeks and 12 months with Visick scores. Anatomical results were assessed with barium studies at between 6 and 12 months. Thirty-five laparoscopic reoperations were performed in 20 women and 13 men (median age 56 years). Primary surgery had been performed in our unit in 27 (77%) and elsewhere in eight (23%). Median time from primary surgery was 28.5 months (5-360). Two patients underwent a second reoperation. Indication was recurrent reflux in 28 (80%), dysphagia in five (14%) and gas bloat in two (6%). Thirty-two of the 35 reoperations (91.4%) were completed laparoscopically, median operating time was 120.5 min (65-210) and median hospital stay 2 days. There was no mortality and there were only five minor complications. Twelve-month follow-up was available for 32 reoperations (91%). Overall good symptomatic outcomes were obtained in 26 (74%) Visick I or II at 6 weeks and 24 of 32 (75%) at 12 months. In reoperations for dysphagia/gas bloat there was a relative risk of 4.26 of a poor symptomatic outcome (Visick III or IV) at 12 months compared to those for recurrent reflux (P < 0.05, Fisher's exact test). Laparoscopic reoperation is feasible with low conversion rates and minimal morbidity for patients who have undergone previous abdominal or thoracic hiatal repair. Symptomatic outcomes are generally good, particularly if the indication is recurrent reflux.

Prosthetic mesh repair of large and recurrent diaphragmatic hernias

BACKGROUND

Laparoscopic repair of large paraesophageal hernias (PEH) is associated with significant recurrence rates. Use of prosthetic mesh to complete tension-free repair of the hiatus has been suggested to decrease the recurrence rate.

METHODS

Fifty-nine patients with large (n = 44) or recurrent (n = 15) PEH were operated on via the laparoscopic approach with the use of prosthetic mesh. Patients were followed with office visits and phone interviews. All patients were referred for barium studies. Data analysis included all patients, including conversions, on an intention-to-treat basis.

RESULTS

Followup was completed in 56 (95%) patients. Mean followup time was 28.4 months. Forty patients (74%) had significant relief of all symptoms. Barium studies were performed in 45 patients (80.3%), including all symptomatic patients. Fifteen patients (33%) had a small sliding hernia, six (13.3%) had recurrent PEH, and four (8.8%) had narrowing of the gastroesophageal junction. Most patients with small hiatal hernias were symptomatic (60%). All responded to medical treatment.

CONCLUSIONS

Laparoscopic repair of large PEH with reinforcement mesh is feasible and safe with excellent short-term results. Long-term followup shows a low PEH recurrence requiring reoperation, but a significant number of patients develop symptomatic recurrent small hiatal hernias that can be managed nonoperatively.

Gastrectomy as a remedial operation for failed fundoplication

The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997-2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients' overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty.

Effect of Nissen fundoplication on gastric motor and sensory functions

OBJECTIVES

Bloating, abdominal pain, and early satiety have been reported in up to 30% of patients after Nissen fundoplication. We hypothesized that these postsurgical complications in children and young adults are linked to either the effects of surgery on gastric sensation, compliance or motor function or to preexisting physiological abnormalities.

METHODS

We prospectively evaluated the effect of Nissen fundoplication on gastric sensory and motor functions in 13 children with gastroesophageal reflux. Gastric barostat and mixed meal gastric emptying studies were performed before surgery in all patients and were repeated after surgery in 8 and 9 children, respectively.

RESULTS

Thirteen patients (median age, 7 years; range, 6 months to 18 years) underwent open Nissen (n = 6) or laparoscopic Nissen fundoplication (n = 7). After fundoplication, patients had significantly higher minimal distending pressure values (10 mm Hg vs 3 mm Hg pre-Nissen, respectively; P < 0.001), reduced gastric compliance (slope values of 8.39 mm Hg vs 9.15 mm Hg, respectively, P < 0.001) and significantly higher pain scores (P < 0.001). Presurgery and postsurgery gastric emptying at 60, 90 and 120 minutes after feeding showed no significant changes.

CONCLUSIONS

After Nissen fundoplication, children with gastroesophageal reflux manifest the following: (1) reduction in gastric compliance, (2) increase in minimal gastric distending pressure, (3) exacerbation of the sensations discomfort with gastric distension and (4) no effect on gastric emptying.

Complications after surgery for gastroesophageal reflux disease

Most complications after surgery for GERD can be avoided by experience and proper surgical technique. Often, what is termed a "slipped" or "twisted" wrap is one that was not properly constructed during the initial surgery. These technical errors can be avoided by complete mobilization of the stomach and esophagus, removal of the epigastric fat pad to identify esophageal shortening, and preservation of both vagus nerves. It is critical to avoid these errors, because an improperly constructed wrap will probably condemn the patient to significant dysphagia, recurrent reflux, and the need for reoperation. Should reoperation be required, the wrap should be completely dismantled so the technical error can be identified and a proper antireflux mechanism created.

Barrett's esophagus: the role of laparoscopic fundoplication

BACKGROUND

To review our early operative results and endoscopic findings after laparoscopic fundoplication for Barrett's esophagus (BE).

METHODS

From January 1995 through December 2000, 49 patients with BE (35 men and 14 women) underwent laparoscopic antireflux surgery. Median age was 54 years (range, 28 to 85 years). No patient had high-grade dysplasia; 6, however, had low-grade dysplasia. All 49 patients had gastroesophageal reflux symptoms. Heartburn was present in 41 patients (84%), dysphagia in 16 (33%), epigastric or chest pain in 9 (18%), and other symptoms in 16 (33%). A Nissen fundoplication was performed in 48 patients and a partial posterior fundoplication in 1. Forty-one patients (84%) had concomitant hiatal hernia repair.

RESULTS

There were no deaths. Complications occurred in 2 patients (4%). Follow-up was complete in 48 patients (98%) and ranged from 1 to 81 months (median, 29 months). Functional results were classified as excellent in 33 patients (69%), good in 9 (19%), fair in 5 (10%), and poor in 1 (2%). Thirty-three patients (67%) underwent postoperative surveillance esophagoscopy with biopsy. Nine patients (18%) had total regression of BE and 3 (6%) had a decrease in total length. In the 6 patients with preoperative low-grade dysplasia, dysplasia was not found in 4, remained unchanged in 1, and progressed to in situ adenocarcinoma in 1.

CONCLUSIONS

Laparoscopic fundoplication is effective in controlling symptoms in the majority of patients with BE. While disappearance of BE may occur in some patients, the possibility of developing esophageal adenocarcinoma is not eliminated by laparoscopic fundoplication. Therefore, endoscopic surveillance should continue.

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.

Results of surgical treatment for recurrent postoperative gastroesophageal reflux

The rate of recurrence of reflux esophagitis after classic antireflux surgery (fundoplication) is 10-15%. This rate is different in patients with esophagitis with and without Barrett's esophagus. We evaluated the clinical and laboratory findings in 104 patients with postoperative recurrent reflux esophagitis, determining the results of repeat antireflux surgery or an acid suppression-bile diversion procedure. Repeat fundoplication was performed in 26 patients, and truncal vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy in 78 patients. Esophagectomy as a third operation was performed in seven patients. After repeat antireflux surgery, endoscopic evaluation demonstrated improvement of esophagitis in a small proportion of patients. Barrett's esophagus remained unchanged, and no regression of ulcer or stricture was observed. These complications improved significantly after acid suppression-bile diversion surgery. Incompetent lower esophageal sphincter (LES) was present in 55.8% after initial surgery and in 23% after reoperation. Acid reflux, initially present in 94.6% of patients, was also observed in 93.6% after fundoplication, 68.8% after redo fundoplication, and 16.6% after treatment with the acid suppression-bile diversion technique. A positive Bilitec test was present in 78% of patients before the operation and 56.6% after the repeat operation, and was negative after bile diversion surgery. Among 13 patients (50%) submitted to repeat surgery alone, esophagectomy as a third operation was necessary as a result of severe non-dilatable stricture in seven patients. Our conclusions are that repeat antireflux surgery alone failed to improve Barrett's esophagus complications and that the best results were obtained in patients submitted to acid suppression-bile diversion surgery.

Surgical and endoscopic treatment of gastroesophageal reflux disease

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.

Outcomes after minimally invasive reoperation for gastroesophageal reflux disease

BACKGROUND

Reoperative antireflux surgery is complex and traditionally performed by open methods. Increasingly, surgeons are performing minimally invasive reoperations. This report summarizes our experience with laparoscopic reoperative antireflux surgery (LRAS).

METHODS

A retrospective review (1996 to 2001) identified 80 LRAS cases. Median age was 49 (22 to 80) years with 52 females and 28 males. Primary symptoms included heartburn (53%), regurgitation (22%), and dysphagia (25%). Detailed outcomes recorded at follow-up included heartburn severity using the Gastroesophageal Reflux Disease-Health Related Quality of Life scale (HRQOL) and SF36 physical (PCS) and mental (MCS) component summary scores.

RESULTS

LRAS was completed in 97.5% of cases (two conversions). The most common problems identified were mediastinal migration of the wrap in 48 (60%) and misplaced wrap in 11 (13.8%). LRAS operations included Collis-Nissen (42), Nissen (26), Toupet (six), and six others. Pyloroplasty was required in nine (11%). Complications occurred in 16 patients. These included nine minor gastric perforations (all repaired intraoperatively) and two reoperations for complications (1 patient with a bile leak and the second with a pyloroplasty site leak). Median length of stay was 2.5 days. Median follow-up was 18 (1 to 52) months; 18 (23%) required proton-pump inhibitors. Detailed outcomes were available in 50 patients. Mean PCS and MCS scores were 42 and 47, respectively (normals = 50). HRQOL scores were excellent in 35 (65%), satisfactory in 9 (17%), and poor in 10 (18%). Ten patients (18%) reported that they were dissatisfied.

CONCLUSIONS

LRAS can be performed safely with complication and success rates similar to open operations in a center with extensive laparoscopic experience.

Anti-reflux surgery in the laparoscopic era

The introduction of laparoscopic anti-reflux surgery has led to a renewed interest in the operative treatment of gastro-oesophageal reflux disease (GORD). Three groups of patients can be identified who are particularly suited to laparoscopic anti-reflux surgery. Failure to respond to medical treatment has been historically the main determinant for those referred for anti-reflux surgery. With the availability of modern anti-secretory drugs most patients with chronic GORD can control their symptoms adequately by these means. Even effective medical therapy, however, is not without problems. In many patients rapid and consistent relapse of symptoms and oesophagitis occurs on cessation of therapy. Some of these patients do not want to be reliant on a form of medication that has yet to firmly establish its record for safety over many years of continued use. A second readily identifiable group of patients are those who are often described as 'volume refluxers'. They are bothered by persistent fluid regurgitation despite adequate control of their heartburn with acid suppressive drugs. Third there are those individuals who develop oesophageal strictures and those with Barrett's oesophagus and concomitant reflux symptoms and also those with respiratory complications associated with presumed aspiration of gastric juice into the pharynx and into the respiratory tree. The low morbidity associated with laparoscopic surgery that has been achieved in the best modern series means that the pendulum may swing back to surgery and therefore it is even more important that the right operation (fundoplication) is done for the right patient. Failure to create an adequate crural repair behind the wrap is associated with a risk of early post-operative para-oesophageal herniation and proximal wrap migration. The question of tailored anti-reflux surgery based on the pre-operative motor function of the body of the oesophagus is widely applied, although the scientific basis for these selective approaches is rather weak. Partial fundoplication seems to be associated with very low rates of dysphagia and of gas bloat. Assessment of the post-operative result should ideally be done by an independent observer and should consider not only traditional outcome measures but also the impact of surgery on the quality of the patient's life. Investigations on the cost effectiveness of these surgical therapeutic strategies suggest important benefits of surgery, which should be incorporated into the clinical decision process when assessing different long-term management alternatives for patients with chronic GORD.

The stapled, uncut gastroplasty for hiatal hernia: 24 years' follow-up

A simple, tension-free, in situ gastroplasty was devised in the late 1960s and early 1970s to avoid the recurrences and complications of the Collis and Nissen hiatal hernioplasties. Long-term follow-up has now been completed on 153 patients. For this procedure, the anterior gastric wall is stapled, not cut, and the fundoplication is performed on the cardia and the neoesophagus created by the stapling and is sutured under the diaphragm. A total of 161 patients underwent the stapled, uncut gastroplasty and were followed for up to 24 years. Conditions included reflux in 145, organic stricture in 23, giant hiatal hernia in 14 (with or without obstruction) and collagen esophagus in six. Post-operative tests included subjective symptom evaluation by questionnaire, esophageal manometry and 24-h pH monitoring. Of the total 161 patients, 89 were followed up for 2-10 years and 64 for 1-24 years; seven were lost to follow-up and one died soon after the operation. The stapled, uncut gastroplasty and fundoplication produced 95% excellent and good results (Matthews classification grade I and II). After the procedure, the esophagus was significantly lengthened (from 2.55 +/- 0.96 to 3.2 +/- 0.32 cm; p < 0.001) and sphincter pressure was significantly increased (from 6.35 +/- 3.5 to 27.3 +/- 6.82 mmHg; p < 0.0001). No leakage, bleeding, or 'slipped' recurrence was observed. Only one patient experienced dissolution of the wrap and recurrent symptoms. Aspiration, scleroderma, stricture and short esophagi, post-gastrectomy gastric remnants and hiccups were treated with excellent and good long-term results. The stapled, uncut gastroplasty has universal application with excellent results, not only in typical cases of gastroesophageal reflux, but also in complicated situations such as short esophagus, strictures, or dysperistaltic and aperistaltic esophagus.

Life after antireflux surgery

Laparoscopic fundoplication technique has become the operative modality of choice for antireflux surgery. An increasing number of patients and physicians have enthusiastically embraced this "minimally-invasive" technologic development for treatment of gastroesophageal reflux disease (GERD). However, laparoscopic fundoplication has been frequently advertised as the therapeutic solution for all GERD patients. Subsequently, the number and severity of complications resulting from laparoscopic surgery--often performed indiscriminately--has increased dramatically. This article reviews the efficacy of the laparoscopic fundoplication operation for GERD based on current, relatively short-term reports from centers specializing in this treatment modality. The majority of these reports are very positive. Unfortunately, the results of fundoplication operations performed by community surgeons are unknown. There are a number of disturbing factors relating to laparoscopic treatment for GERD that should raise a red flag of caution to the medical community, particularly primary-care physicians and their patients. The central portion of this report devotes itself to discussing the problems associated with this new minimally-invasive technique for fundoplication operations. These problems include the selectivity of current reports on outcomes of the laparascopic fundoplication operation and the lack of uniform data acquisition associated with these postoperative studies. The technical difficulties of the laparascopic fundoplication surgery are discussed, and the need for operator expertise and appreciation of esophageal physiology and anatomy are stressed. Finally, the long-term durability of the fundoplication wrap is questioned and the morbidity associated with the operation--particularly dysphagia--is addressed. In the final segment, the complications encountered after laparoscopic fundoplication operations are detailed and the techniques for evaluating the symptomatic postfundoplication patient are discussed. Laparoscopic fundoplication operation is good therapy in an appropriate clinical setting when performed by a well-trained and experienced surgeon. However, the operation should not be first-line therapy for the majority of GERD patients. An esophagus disabled by an inappropriate or dysfunctional fundoplication wrap is a terrible price to pay for control of acid reflux.

Surgical treatment for recurrent gastro-oesophageal reflux disease after failed antireflux surgery

BACKGROUND

Recurrent or persistent symptoms occur in 10-15 per cent of patients after antireflux surgery. Failure of surgery is not uniform in its presentation. The cause of failure is not easily detected and even harder to treat. Different approaches have been proposed and few reports are available on the objective and subjective outcome of reoperation.

METHODS

This study focuses on 30 patients (16 men and 14 women; age range 20-69 years) with recurrent symptomatic gastro-oesophageal reflux disease (GORD) resistant to medical treatment. In all patients reoperation was by the Belsey Mark IV antireflux operation. A clinical history, endoscopy and oesophageal manometry were obtained in all patients, and 24-h pH monitoring was performed in 27 of 30 before and in most patients after the Belsey procedure.

RESULTS

Symptomatic improvement was reported in 24 of 30 patients. Oesophagitis (present before operation in 19 patients) was cured or remained absent in 24 of 30 patients, stabilized in one, improved in four and deteriorated in one. Relief of symptoms combined with absence of oesophagitis was obtained in 21 of 30 patients, with concomitant normalization of the 24-h pH profile in 11 of 22 patients. The median basal lower oesophageal sphincter (LOS) pressure increased significantly from 6. 9 to 9.0 mmHg (P < 0.01). Redo surgery had no effect on oesophageal body motility.

CONCLUSION

Reoperation performed for documented recurrent GORD had a good and lasting effect on symptoms, on oesophagitis (both in 24 of 30 patients) and on the combination of both (21 of 30). In these patients reoperation increased basal LOS pressure and decreased reflux time. Overall, the results approximate to those of primary operation.

Laparoscopic refundoplications after failed antireflux surgery

BACKGROUND

Open and laparoscopic antireflux procedures may require reoperation for failures of the initial procedure in about 3% to 6% of cases. The purpose of this study is to describe our operative experiences, postoperative results, and patients' view of outcome following laparoscopic refundoplication.

METHODS

Thirty patients (18 men, 12 women), mean age 56 years (range 37 to 77) underwent laparoscopic redo surgery. In 18 patients the initial surgery was done by the open technique, and 3 had surgery twice previously. Twelve patients had previous laparoscopic antireflux surgery. Indications for redo surgery were recurrent reflux (n = 17), dysphagia (n = 6), and the combination of both (n = 7).

RESULTS

Twenty-eight patients were completed laparoscopically, 21 with a floppy Nissen and 7 with a Toupet fundoplication. Two patients were converted to the open procedure because of intraoperative technical problems. In 5 cases there was an injury to the stomach wall, successfully managed laparoscopically. Postoperatively 1 patient had dysphagia and required pneumatic dilatation, another had gas bloat. There was a significant increase in lower esophageal sphincter pressure at 3 months (12.4+/-4.8 mm Hg; n = 30) and 1 year (12.3+/-4.5 mm Hg; n = 30). Twenty-four hour pH monitoring showed a decrease of the DeMeester Score at 3 months after surgery from 14.7+/-10.6 (n = 30) and 1 year after surgery from 12.1+/-8.7 (n = 30). Gastrointestinal quality of life index increased from 87 points preoperatively to 121 at 3 months and 123 at 1 year, which is comparable with a healthy population (123 points).

CONCLUSIONS

Laparoscopic refundoplication is a feasible and effective procedure with excellent postoperative results, independent of whether the primary procedure was done by the open or laparoscopic technique.

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.

Early experience and learning curve associated with laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic approach for hiatal hernia repair is relatively new. Information on the learning curve is limited.

METHODS

From January 1994 to September 1996, 280 patients underwent antireflux surgery at our institution. A laparoscopic repair was attempted in 60 patients (21.4%). There were 38 men and 22 women. Median age was 49 years (range 21 to 78 years). Indications for operation were gastroesophageal reflux in 59 patients and a large paraesophageal hernia in one. A Nissen fundoplication was performed in all patients; 53 (88.3%) had concomitant hiatal hernia repair.

RESULTS

In eight patients (13.3%) the operation was converted to an open procedure. Median operative time for the 52 patients who had laparoscopic repair was 215 minutes (range 104 to 320 minutes). There were no deaths. Complications occurred in five patients (9.6%). Median hospitalization was 2 days (range 1 to 5 days). Median operative time and median hospitalization were significantly longer in the first 26 patients than in the subsequent 25 patients (248 vs 203 minutes and 2 days vs 1 day, respectively; p = 0.03). Seven of the first 30 patients (23.3%) required laparotomy as compared with two of the second 30 (6.7%) (p = 0.07). Follow-up in the 51 patients who had laparoscopic fundoplication for reflux was complete in 50 (98.0%) and ranged from 7 to 38 months (median 13 months). Functional results were classified as excellent in 34 patients (68.0%), good in 6 (12.0%), fair in 7 (14.0%), and poor in 3 (6.0%). Three patients were reoperated on for recurrent reflux symptoms at 5, 5, and 11 months.

CONCLUSIONS

We conclude that laparoscopic Nissen fundoplication can be performed safely. The operative time, hospitalization, and conversion rate to laparotomy are higher during the early part of the experience, but all are reduced after the learning curve.