Laparoscopic redo Nissen fundoplication

Transoral incisionless fundoplication for recurrent symptoms after laparoscopic fundoplication

BACKGROUND

Revision of a failed laparoscopic fundoplication carries higher risk of complication and lower chance of success compared to the original surgery. Transoral incisionless fundoplication (TIF) may be an endoscopic alternative for select GERD patients without need of a moderate/large hiatal hernia repair. The aim of this study was to assess feasibility, efficacy, and safety of TIF 2.0 after failed laparoscopic Nissen or Toupet fundoplication (TIFFF).

METHODS

This is a multicenter retrospective cohort study of patients who underwent TIFFF between September 2017 and December 2020 using TIF 2.0 technique (EsophyX Z/Z+) performed by gastroenterologists and surgeons. Patients were included if they had (1) recurrent GERD symptoms, (2) pathologic reflux based upon pH testing or Grade C/D esophagitis or Barrett's esophagus, and (3) hiatal hernia ≤ 2 cm. The primary outcome was improvement in GERD Health-Related Quality of Life (GERD-HRQL) post-TIFFF. The TIFFF cohort was also compared to a similar surgical re-operative cohort using propensity score matching.

RESULTS

Twenty patients underwent TIFFF (median 4.1 years after prior fundoplication) and mean GERD-HRQL score improved from 24.3 ± 22.9 to 14.75 ± 21.6 (p = 0.014); mean Reflux Severity Index (RSI) score improved from 14.1 ± 14.6 to 9.1 ± 8.0 (p = 0.046) with 8/10 (80%) of patients with normal RSI (< 13) post-TIF. Esophagitis healed in 78% of patients. PPI use decreased from 85 to 55% with 8/20 (45%) patients off of PPI. Importantly, mean acid exposure time decreased from 12% ± 17.8 to 0.8% ± 1.1 (p = 0.028) with 9/9 (100%) of patients with normalized pH post-TIF. There were no statistically significant differences in clinical efficacy outcomes between TIFFF and surgical revision, but TIFFF had significantly fewer late adverse events.

CONCLUSION

Endoscopic rescue with TIF is a safe and efficacious alternative to redo laparoscopic surgery in symptomatic patients with appropriate anatomy and objective evidence of persistent or recurrent reflux.

A Comparison of Laparoscopic Redo Fundoplications for Failed Toupet and Nissen Fundoplications in Children

Purpose:

We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs).

Methods:

Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0–3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome.

Results:

Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date.

Conclusion:

Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.

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.

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.

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.

Revision Nissen fundoplication can be completed laparoscopically with a low rate of complications: a single-institution experience with 72 children

PURPOSE

Recurrent gastroesophageal reflux is a common complication after fundoplication and is often treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication.

METHODS

The medical records of all patients in whom laparoscopic revision fundoplication was attempted over a 7 1/2-year period were reviewed.

RESULTS

Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of first-time redo operations and 68% of second revisions with average operative times of 2.2 +/- 1.0 and 2.6 +/- 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%) and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with dissection or visualization. No patients required intraoperative transfusion. No patients required reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the 72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth.

CONCLUSION

Revision laparoscopic fundoplication is a technically challenging operation but can usually be completed and is characterized by a low rate of complications.

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.

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.

Medical or surgical therapy for erosive reflux esophagitis: cost-utility analysis using a Markov model

OBJECTIVE

To compare the cost and utility of healing and maintenance regimens of omeprazole and laparoscopic Nissen fundoplication (LNF) in the framework of the Canadian medical system.

SUMMARY BACKGROUND DATA

Medical therapy with proton pump inhibitors for endoscopically proven reflux esophagitis is a safe and effective treatment option. Of late, the surgical treatment of choice for this disease has become LNF.

METHODS

The authors' base case was a 45-year-old man with erosive reflux esophagitis refractory to H2-blockers. A cost-utility analysis was performed comparing the two strategies. A two-stage Markov model (healing and maintenance phases) was used to estimate costs and utilities with a time horizon of 5 years. Discounted direct costs were estimated from the perspective of a provincial health ministry, and discounted quality-of-life estimates were derived from the medical literature. Sensitivity analyses were performed to test the robustness of the model to the authors' assumptions and to determine thresholds. A Monte Carlo simulation of 10,000 patients was used to estimate variances and 95% interpercentile ranges.

RESULTS

For the 5-year period studied, LNF was less expensive than omeprazole (3519.89 dollars vs. 5464.87 dollars per patient) and became the more cost-effective option at 3.3 years of follow-up. The authors found that 20 mg/day omeprazole would have to cost less than 38.60 dollars per month before medical therapy became cost effective; conversely, the cost of LNF would have to be more than 5,273.70 dollars or the length of stay more than 4.2 days for medical therapy to be cost effective. Estimates of quality-adjusted life-years did not differ significantly between the two treatment options, and the incremental cost for medical therapy was 129,665 dollars per quality-adjusted life-years gained.

CONCLUSIONS

For patients with severe esophagitis, LNF is a cost-effective alternative to long-term maintenance therapy with proton pump inhibitors.

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.