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Schietroma M, Romano L, Tomarelli C, Carlei F, Tonelli E, Giuliani A. Dysphagia After Laparoscopic Nissen Fundoplication: Incidence, Causes, Prevention, and Treatment. Indian J Surg 2022. [DOI: 10.1007/s12262-021-02973-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Elmously A, Gray KD, Ullmann TM, Fahey TJ, Afaneh C, Zarnegar R. Robotic Reoperative Anti-reflux Surgery: Low Perioperative Morbidity and High Symptom Resolution. World J Surg 2018; 42:4014-4021. [DOI: 10.1007/s00268-018-4708-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Singhal S, Kirkpatrick DR, Masuda T, Gerhardt J, Mittal SK. Primary and Redo Antireflux Surgery: Outcomes and Lessons Learned. J Gastrointest Surg 2018; 22:177-186. [PMID: 28681211 DOI: 10.1007/s11605-017-3480-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 06/15/2017] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Saurabh Singhal
- Creighton University School of Medicine, Omaha, NE, USA
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | | | - Takahiro Masuda
- Creighton University School of Medicine, Omaha, NE, USA
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | | | - Sumeet K Mittal
- Creighton University School of Medicine, Omaha, NE, USA.
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA.
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Abstract
PURPOSE OF REVIEW We aim to review the endoscopic evaluation of post-fundoplication anatomy and its role in assessment of fundoplication outcomes and in pre-operative planning for reoperation in failed procedures. RECENT FINDINGS There is no universally accepted system for evaluating post-fundoplication anatomy endoscopically. However, multiple reports described the usefulness of post-operative endoscopy as a quality control measure and in the evaluation of complex cases such as repeat procedures and paraesophageal hernias (PEH). Endoscopic evaluation of post-fundoplication anatomy has an important role in assessing the outcomes of operative repair and pre-operative planning for failed fundoplications. Attempts have been made to characterize the appearance of the newly formed gastroesophageal valve after successful repairs and to standardize endoscopic reporting and classification of anatomic descriptions of failed fundoplications. However, there is no consensus. More studies are needed to evaluate the applicability and reproducibility of proposed endoscopic evaluation systems in order for such tools to become widely accepted.
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Schwameis K, Zehetner J, Rona K, Crookes P, Bildzukewicz N, Oh DS, Ro G, Ross K, Sandhu K, Katkhouda N, Hagen JA, Lipham JC. Post-Nissen Dysphagia and Bloating Syndrome: Outcomes After Conversion to Toupet Fundoplication. J Gastrointest Surg 2017; 21:441-445. [PMID: 27834011 DOI: 10.1007/s11605-016-3320-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 10/31/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Protracted dysphagia and bloating are potential troublesome side effects following Nissen fundoplication. The aim of this study was to evaluate the effects of conversion from Nissen to Toupet on dysphagia and bloating. METHODS The study used a retrospective chart review of all patients who had undergone conversion from Nissen to Toupet between 2001 and 2014. Endpoints were to determine the effect of conversion on dysphagia, bloating, and reflux control. RESULTS Twenty-five patients underwent conversion at a median of 3.7 years (1.4-10.5) after initial fundoplication. Indications were dysphagia in 19 (76%) and bloating syndrome in 6 (24%) patients. The median operative time was 104 min (86-146). There were no serious complications or mortality. Median follow-up was 27 months (0.8-130). Dysphagia was relieved in 16 (84%) and bloating in all 6 patients. Two patients developed reflux requiring a redo-Nissen. Two patients had persistent dysphagia and required endoscopic dilation. The GERD-HRQL post-conversion showed a median score of 5 (3-13). CONCLUSIONS Conversion relieved dysphagia in 84% and bloating in 100%. Significant recurrence of GERD was rare. Given the absence of serious complications, conversion should be considered in patients with severe bloating or dysphagia.
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Affiliation(s)
- Katrin Schwameis
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Jörg Zehetner
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Kais Rona
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Peter Crookes
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Nikolai Bildzukewicz
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Daniel S Oh
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Geoffrey Ro
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Katherine Ross
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Kulmeet Sandhu
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Namir Katkhouda
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - Jeffrey A Hagen
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA
| | - John C Lipham
- Division of Upper GI & General Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, #514, 90033, Los Angeles, CA, USA.
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Awais O, Luketich JD, Reddy N, Bianco V, Levy RM, Schuchert MJ, Gooding WE, Crist LR, Landreneau RJ, Pennathur A. Roux-en-Y near esophagojejunostomy for failed antireflux operations: outcomes in more than 100 patients. Ann Thorac Surg 2014; 98:1905-1913. [PMID: 25442998 DOI: 10.1016/j.athoracsur.2014.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 07/07/2014] [Accepted: 07/07/2014] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Omar Awais
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James D Luketich
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Neha Reddy
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Valentino Bianco
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ryan M Levy
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - William E Gooding
- The University of Pittsburgh Cancer Institute Biostatistics Facility, Pittsburgh, Pennsylvania
| | - Lawrence R Crist
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rodney J Landreneau
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arjun Pennathur
- Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Xuan Y, Kim JY, Hur H, Cho YK, Thu VD, Han SU. Robotic redo fundoplication for incompetent wrapping after antireflux surgery: A case report. Int J Surg Case Rep 2011; 2:278-281. [PMID: 22096753 PMCID: PMC3215201 DOI: 10.1016/j.ijscr.2011.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 09/01/2011] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Incidence of gastroesophageal reflux disease (GERD) is high. antireflux surgery with specific indications could be an option. Nissen fundoplication is the most popular surgical procedure for GERD, and recent results using laparoscopy have reported excellent short- and mid-term results. Regarding surgical outcome of antireflux surgery, the rate of complications has been reported as below 2.4%, but rare cases still require reoperation. PRESENTATION OF CASE A 53-year old male patient underwent laparoscopic Nissen fundoplication three years ago owing to gastroesophageal reflux disease (GERD) troubled by dysphagia and heartburn However, despite undergoing surgery, his symptoms did not show improvement .A robotic redo fundoplication was planned. The patient recovered uneventfully, and the esophagography on postoperative day four revealed improvement of previous upward contrast reflux and distension of the distal esophagus during swallowing had disappeared. Dysphagia and heartburn had still not occurred at one year follow-up. DISCUSSION Redo antireflux surgery for postoperative stricture is not an easy procedure due to postoperative adhesion and anatomical change. Robotic surgery may be more helpful for precise dissection of the adhesion site by a previous operation and robotic suturing for re-fundoplication was more effective. CONCLUSION Re-do fundoplication using a robot, which is a complicated procedure compared with primary anti-reflux surgery would be a general procedure in the near future.
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Affiliation(s)
| | | | | | | | | | - Sang-Uk Han
- Department of Surgery, School of Medicine, Ajou University, Suwon, Korea
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Furnée EJB, Draaisma WA, Broeders IAMJ, Gooszen HG. Surgical reintervention after failed antireflux surgery: a systematic review of the literature. J Gastrointest Surg 2009; 13:1539-49. [PMID: 19347410 PMCID: PMC2710493 DOI: 10.1007/s11605-009-0873-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Accepted: 03/12/2009] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Edgar J. B. Furnée
- Department of Surgery, H.P. G04.228, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Werner A. Draaisma
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
| | | | - Hein G. Gooszen
- Department of Surgery, H.P. G04.228, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Furnée EJB, Draaisma WA, Broeders IAMJ, Smout AJPM, Vlek ALM, Gooszen HG. Predictors of symptomatic and objective outcomes after surgical reintervention for failed antireflux surgery. Br J Surg 2008; 95:1369-74. [PMID: 18844266 DOI: 10.1002/bjs.6346] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- E J B Furnée
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Awais O, Luketich JD, Tam J, Irshad K, Schuchert MJ, Landreneau RJ, Pennathur A. Roux-en-Y near esophagojejunostomy for intractable gastroesophageal reflux after antireflux surgery. Ann Thorac Surg 2008; 85:1954-1961. [PMID: 18498802 DOI: 10.1016/j.athoracsur.2008.01.072] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 01/22/2008] [Accepted: 01/23/2008] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Omar Awais
- The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Ohnmacht GA, Deschamps C, Cassivi SD, Nichols FC, Allen MS, Schleck CD, Pairolero PC. Failed antireflux surgery: results after reoperation. Ann Thorac Surg 2007; 81:2050-3; discussion 2053-4. [PMID: 16731129 DOI: 10.1016/j.athoracsur.2006.01.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 01/03/2006] [Accepted: 01/04/2006] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Galen A Ohnmacht
- Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Chang EY, Minjarez RC, Kim CY, Seltman AK, Gopal DV, Diggs B, Davila R, Hunter JG, Jobe BA. Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing. Surg Endosc 2007; 21:1719-25. [PMID: 17345143 DOI: 10.1007/s00464-007-9234-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 11/03/2006] [Accepted: 11/20/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans. METHODS The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting. RESULTS The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods. CONCLUSION According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.
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Affiliation(s)
- E Y Chang
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
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Williams VA, Watson TJ, Gellersen O, Feuerlein S, Molena D, Sillin LF, Jones C, Peters JH. Gastrectomy as a remedial operation for failed fundoplication. J Gastrointest Surg 2007; 11:29-35. [PMID: 17390183 DOI: 10.1007/s11605-006-0048-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Valerie A Williams
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA
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Gopal DV, Chang EY, Kim CY, Sandone C, Pfau PR, Frick TJ, Hunter JG, Kahrilas PJ, Jobe BA. EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure. Gastrointest Endosc 2006; 63:35-44. [PMID: 16377313 DOI: 10.1016/j.gie.2005.08.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Accepted: 08/03/2005] [Indexed: 12/10/2022]
Abstract
BACKGROUND In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication. METHODS EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined. RESULTS EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern. CONCLUSIONS EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.
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Affiliation(s)
- Deepak V Gopal
- Section of Gastroenterology and Hepatology, University of Wisconsin-Hospitals and Clinics, Madison, Wisconsin, USA
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16
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Wykypiel H, Kamolz T, Steiner P, Klingler A, Granderath FA, Pointner R, Wetscher GJ. Austrian experiences with redo antireflux surgery. Surg Endosc 2005; 19:1315-9. [PMID: 16206012 DOI: 10.1007/s00464-004-2208-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Accepted: 05/10/2005] [Indexed: 12/18/2022]
Abstract
BACKGROUND From 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results. METHODS A questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms). RESULTS Out of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach. CONCLUSION Laparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience.
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Affiliation(s)
- H Wykypiel
- Department of General and Transplant Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Abstract
Functional problems following esophageal surgery for GERD are not infrequent. The majority of patients improve with time. Careful patient selection and attention to surgical technique are key factors in preventing such functional disorders. When anatomic abnormalities related to the fundoplication are identified, reoperation may offer symptom relief. Before embarking on re-fundoplication, a thorough preoperative evaluation of the esophageal physiology is recommended.
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Affiliation(s)
- Pavlos Papasavas
- Temple University School of Medicine at the Western Pennsylvania Hospital Clinical Campus, 4800 Friendship Avenue, Pittsburgh, Pennsylvania 15224, USA.
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Altorjay A, Juhasz A, Kellner V, Sohar G, Fekete M, Sohar I. Metabolic changes in the lower esophageal sphincter influencing the result of anti-reflux surgical interventions in chronic gastroesophageal reflux disease. World J Gastroenterol 2005; 11:1623-8. [PMID: 15786538 PMCID: PMC4305942 DOI: 10.3748/wjg.v11.i11.1623] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: With the availability of a minimally invasive approach, anti-reflux surgery has recently experienced a renaissance as a cost-effective alternative to life-long medical treatment in patients with gastroesophageal reflux disease (GERD). We are not aware of the fact whether reflux episodes causing complaints for a long time i.e., at least for one year are associated with metabolic changes in the lower esophageal sphincter, and if so, whether these may influence functional results achieved after anti-reflux surgery.
METHODS: Between 1 January 2001 and 31 December 2002 we performed anti-reflux surgery on 79 patients. Muscle samples were taken from the lower esophageal sphincter (LES) in 33 patients during anti-reflux surgery. Inclusion criteria were: LES resting pressure below 10 mmHg and a marked, pH proven acid exposure to the esophagus of at least one year’ duration, causing subjective complaints and requiring continuous proton pump inhibitor treatment. Control samples were obtained from muscle tissue in the gastroesophageal junction that had been removed from 17 patients undergoing gastric or esophageal resection. Metabolic and lysosomal enzyme activities and special protein concentrations 16 parameters in total were evaluated in tissue taken from control specimens and tissue taken from patients with GERD. The biochemical parameters of these intra-operative biopsies were used to correlate the results of anti-reflux operations (Visick I and II-III).
RESULTS: In the reflux-type muscle, we found a significant increase of the energy-enzyme activities e.g., creatine kinase, lactate dehydrogenase, β-hydroxybutyrate dehydrogenase, and aspartate aminotransaminase-. The concentration of the structural protein S-100 and the myofibrillar protein troponin I were also significantly increased. Among lysosomal enzymes, we found that the activities of cathepsin B, tripeptidyl-peptidase I, dipeptidyl-peptidase II, β-hexosaminidase B, β-mannosidase and β-galactosidase were significantly decreased as compared to the control LES muscles. By analyzing the activity values of the 9 patients in Visick groups II and III at two months post-surgery, we found a significant increase in the activity of the so-called energy-enzyme values and in the concentration of structural and myofibrillar proteins as compared to the rest of the reflux patients.
CONCLUSION: Our results call attention to the metabolic changes that occurred in the LES muscles of reflux patients. The developing hypertrophy-like changes of LES muscles may be a reason for complaints after anti-reflux surgery, which consisted mainly of reports of persisting dysphagia.
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Affiliation(s)
- Aron Altorjay
- Department of Surgery, Saint George University Teaching Hospital, Seregelyesi u. 3., Szekesfehervor, H-8000, Hungary.
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19
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Little AG. Gastroesophageal reflux disease: a historical review of surgical therapy. J Surg Res 2004; 117:30-3. [PMID: 15013711 DOI: 10.1016/j.jss.2003.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2003] [Indexed: 11/30/2022]
Affiliation(s)
- Alex G Little
- Department of Surgery, Wright State University, Dayton, Ohio 45409, USA.
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20
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Braghetto I, Csendes A, Burdiles P, Botero F, Korn O. Results of surgical treatment for recurrent postoperative gastroesophageal reflux. Dis Esophagus 2003; 15:315-22. [PMID: 12472479 DOI: 10.1046/j.1442-2050.2002.00274.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- I Braghetto
- Department of Surgery, Clinical Hospital, University of Chile, Santiago, Chile.
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21
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Booth MI, Dehn TC. Twenty-four-hour pH monitoring is required to confirm acid reflux suppression in patients with Barrett's oesophagus undergoing anti-reflux surgery. Eur J Gastroenterol Hepatol 2001; 13:1323-6. [PMID: 11692058 DOI: 10.1097/00042737-200111000-00010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To assess whether relief of gastro-oesophageal reflux symptoms in patients with Barrett's oesophagus who undergo laparoscopic anti-reflux surgery is a reliable indicator of acid suppression. DESIGN Prospective cohort study. SETTING Surgical department of a large district general hospital. PARTICIPANTS Twenty-two patients with Barrett's oesophagus and symptomatic gastro-oesophageal reflux who underwent laparoscopic anti-reflux surgery. INTERVENTIONS Laparoscopic anti-reflux surgery. MAIN OUTCOME MEASURES Postoperative symptom scores and 24-h pH test results. RESULTS Twenty-one out of 22 patients had no or minimal residual symptoms postoperatively (Visick I or II). DeMeester symptom scores improved from a median of 5 preoperatively to 0 postoperatively (P < 0.001, Mann-Whitney rank sum test). Eighteen out of 22 patients had postoperative pH studies: three had persisting abnormal acid exposure times postoperatively, but all three were asymptomatic. CONCLUSIONS In patients with Barrett's oesophagus, relief of reflux symptoms following laparoscopic anti-reflux surgery is unreliable as an indicator of acid reflux suppression.
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Affiliation(s)
- M I Booth
- Department of Surgery, Royal Berkshire Hospital, Reading, UK
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22
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Abstract
BACKGROUND Dysphagia is experienced by many patients after antireflux surgery. This literature review examines factors associated with the development, prediction and management of postoperative dysphagia. METHODS Published studies examining issues related to dysphagia, gastro-oesophageal reflux and fundoplication were reviewed. RESULTS Postoperative dysphagia is usually temporary but proves troublesome for 5--10 per cent of patients. Technical modifications, such as a partial wrap, division of short gastric vessels and method of hiatal closure, have not conclusively reduced its incidence. There is no reliable preoperative test to predict dysphagia. CONCLUSION It is uncertain whether postoperative dysphagia arises from patient predilection or is largely a consequence of mechanical changes created by fundoplication. Anatomical errors account for a significant proportion of patients referred for correction of dysphagia but these are uncommon in large single-institution studies. Abnormal manometry cannot predict dysphagia and, on current evidence, 'tailoring' the operation does not prevent its occurrence.
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Affiliation(s)
- V L Wills
- St George Upper Gastrointestinal Surgical Unit, 1 South Street, Kogarah, 2217 New South Wales, Australia
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23
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Bais JE, Horbach TL, Masclee AA, Smout AJ, Terpstra JL, Gooszen HG. Surgical treatment for recurrent gastro-oesophageal reflux disease after failed antireflux surgery. Br J Surg 2000; 87:243-249X. [PMID: 10671935 DOI: 10.1046/j.1365-2168.2000.01299.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- J E Bais
- Department of Surgery, University Medical Centre Leiden, Leiden, The Netherlands
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24
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Rantanen TK, Salo JA, Sipponen JT. Fatal and life-threatening complications in antireflux surgery: analysis of 5,502 operations. Br J Surg 1999; 86:1573-7. [PMID: 10594508 DOI: 10.1046/j.1365-2168.1999.01297.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There have been few comprehensive studies relating to the life-threatening or fatal complications of antireflux surgery. METHODS Some 5502 antireflux operations were performed in Finland between January 1987 and January 1996 (population approximately 5 million); 3993 procedures (72.6 per cent) were open fundoplications, 1162 (21.1 per cent) laparoscopic fundoplications and 347 (6.3 per cent) other anti-reflux procedures. RESULTS There were 43 fatal or life-threatening complications (prevalence 0.8 per cent). Twenty-two followed primary open fundoplication (prevalence 0.6 per cent), 15 laparoscopic fundoplication (prevalence 1.3 per cent) (P < 0.05), one refundoplication and five other antireflux procedures. The overall mortality rate was 0.3 per cent. Nine patients (0.2 per cent) died after open fundoplication, one (0.1 per cent) following laparoscopic fundoplication (P = 0.43), one following refundoplication and four after other antireflux procedures. Laparoscopic fundoplication was followed by 14 non-fatal life-threatening complications (prevalence 1.2 per cent), open fundoplication by 13 (prevalence 0.3 per cent) (P < 0.01) and other antireflux procedures by one life-threatening complication (0.3 per cent). CONCLUSION Laparoscopic fundoplication was associated with more life-threatening complications than open fundoplication. This may compromise the advantages of the laparoscopic technique.
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Affiliation(s)
- T K Rantanen
- Department of Surgery, Helsinki University Central Hospital, Finland
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25
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Abstract
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.
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Affiliation(s)
- R Pointner
- Department of surgery, A.ö. Krankenhaus der Stadtgemeinde Zell am See, Austria
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26
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STEYAERT H, ORDORICA-FLORES R, MERROT T, VALLA J. Learning Curve in Laparoscopic Fundoplication in Children. ACTA ACUST UNITED AC 1999. [DOI: 10.1089/pei.1999.3.171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Abstract
BACKGROUND Previous reports of minimally invasive antireflux surgery for gastroesophageal reflux disease (GERD) have been small, short-term series utilizing only a laparoscopic approach. We conducted a retrospective review and report our 66-month experience with more than 1,000 laparoscopic and thoracoscopic antireflux procedures. METHODS Between September 1991 and October 1997, 968 adults underwent 1,003 minimally invasive antireflux procedures on a tailored basis, based on their preoperative evaluation. Procedures performed were laparoscopic Nissen (626), Toupet (348), paraesophageal (33), and thoracoscopic Belsey (22). A total of 23% (233) of patients underwent an ancillary procedure (esophageal myotomy 85, vagotomy 67, pyloromyotomy 13, and cholecystectomy 66). RESULTS Follow-up averaged 33 months (range 1 to 66), operative mortality was 0.1%. Complications occurred in 2.7% with a 1% long-term dysphagia rate. Demonstrated recurrence rate was 3.8% to date, with an associated 3.4% reporting symptoms of GERD. CONCLUSION Minimally invasive antireflux procedures provide sustained relief of GERD symptoms with low morbidity and rapid recovery.
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Affiliation(s)
- J B McKernan
- Department of Surgery, Medical College of Georgia, Augusta, USA
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29
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Kozarek RA, Low DE, Raltz SL. Complications associated with laparoscopic anti-reflux surgery: one multispecialty clinic's experience. Gastrointest Endosc 1997; 46:527-531. [PMID: 9434220 DOI: 10.1016/s0016-5107(97)70008-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The records of all patients with significant complications of laparoscopic anti-reflux surgery (LARS) seen at our institution between June 1993 and September 1996 were reviewed. Specifically excluded were patients who had mild perioperative complications or postoperative dysphagia that either did not require bougienage or responded to one to two dilations. Data collected included patient demographics; type of surgery; complication and its presentation; response to medical, endoscopic, and/or surgical therapy; and outcomes. RESULTS Nine patients (five men and four women, mean age 59 years) presented at a mean of 4 months post-LARS (seven Nissen fundoplications and two Hill posterior gastropexy repairs). Symptoms included refractory dysphagia (4), intractable gas bloat (5), various degrees of chest or abdominal pain (4), and incapacitating diarrhea (3). Findings included tight repair (4), vagal nerve injury with gastroparesis (4) and/or diarrhea (3), and esophageal or gastric perforation (3). Additional findings included proximal gastric ulcers (3), volvulus (1), and incarcerated intrathoracic hernia (1). Patients with dysphagia had moderate improvement after a mean of 3 +/- 0.6 (standard error of the mean) additional dilations, whereas four patients required five reoperations to date. Seven of the nine patients had clinical improvement, whereas two had refractory symptoms at a mean follow-up of 10 months. CONCLUSIONS Although LARS has supplanted open surgery in many centers, refractory complications occur in a subset of patients and require reoperation in approximately one half of those referred to a multispecialty clinic.
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Affiliation(s)
- R A Kozarek
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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Abstract
A further operation is required in a small proportion of patients who have had prior antireflux surgery. This has a surprisingly good chance for success in appropriately evaluated patients. The surgeon must make very specific decisions regarding the surgical approach. The use of laparoscopy for redo surgery is being defined.
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Affiliation(s)
- R A Hinder
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA
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31
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Abstract
Nine patients underwent redo laparoscopic Nissen fundoplication because of failed primary laparoscopic antireflux procedure. Symptoms prior to reoperation included heartburn (n = 5), dysphagia (n = 2), dysphagia and heartburn (n = 1), and early satiety and epigastric pain (n = 1). Endoscopic and radiologic findings prior to reoperation included esophagitis (n = 6), reflux (n = 6), stenosis (n = 2), and hiatal hernia (n = 1). Findings at reoperation included fundoplication positioned on the stomach (n = 5); a disrupted cruroplasty (n = 1); gastric volvulus (n = 1); and an excessively tight wrap (n = 1) or cruroplasty (n = 1). Reconstruction of the fundoplication was performed according to accepted principles for this procedure. All patients were discharged within 2 days after the redo procedure. Follow-up time is 4-14 months. Preoperative symptoms were relieved in all patients and all antireflux medication have been discontinued. Routine postoperative esophagram and endoscopy demonstrated intact repair and without gastroesophageal reflux or stenosis. Reoperative laparoscopic Nissen fundoplication is feasible and effective.
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Affiliation(s)
- C T Frantzides
- Minimally Invasive Surgery Center, Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA
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Deschamps C, Trastek VF, Allen MS, Pairolero PC, Johnson JO, Larson DR. Long-term results after reoperation for failed antireflux procedures. J Thorac Cardiovasc Surg 1997; 113:545-50; discussion 550-1. [PMID: 9081101 DOI: 10.1016/s0022-5223(97)70369-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
From January 1960 to June 1995, 185 patients underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease. There were 102 men and 83 women. Median age was 58 years (range 20 to 84 years). A single previous antireflux operation had been performed in 147 patients, two in 33, and three in 5. The median interval between the reoperation and the previous operation was 36 months (range 1 to 291 months). Indications for reoperation were symptoms in 184 patients and a large paraesophageal hernia in one patients. The surgical approach was by means of a thoracotomy in 133 patients (71.9%), laparotomy in 27 (14.6%), and a thoracoabdominal incision in 25 (13.5%). A Nissen fundoplication was performed in 107 patients (57.8%), Belsey fundoplication in 47 (25.4%), truncal vagotomy and antrectomy with Roux-en-Y reconstruction in 17 (9.2%), anatomic hernia repair in 12 (6.5%), and Hill gastropexy in 2 (1.1%). A Collis gastroplasty was added to the fundoplication in 116 patients (62.7%), and a pyloroplasty was performed in 17 (9.2%). There was one operative death (0.5%). Complications occurred in 47 patients (25.4%). Median postoperative hospitalization was 9 days (range 5 to 58 days). Follow-up was complete in 156 patients (84.3%) and ranged from 3 to 283 months (median 44 months). Improvement occurred in 137 patients (87.8%). Functional results were classified as excellent in 65 patients (41.6%), good in 29 (18.6%), fair in 43 (27.6%), and poor in 19 (12.2%). No single operative approach or procedure proved to be functionally superior. We conclude that reoperation with esophageal preservation after a failed antireflux procedure will result in significant functional benefit and can be performed with low mortality and acceptable morbidity. The type of repair should be tailored to the individual patient.
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Affiliation(s)
- C Deschamps
- Section of General Thoracic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Lim JK, Moisidis E, Munro WS, Falk GL. Re-operation for failed anti-reflux surgery. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1996; 66:731-3. [PMID: 8918378 DOI: 10.1111/j.1445-2197.1996.tb00731.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Between 1993 and 1995, 315 anti-reflux procedures were undertaken on our service. A previous antireflux procedure had been performed in 31 patients referred (10%). Previous surgery was, in the main (80%), a Nissen fundoplication. METHODS Pre-operative investigations in all patients were manometry, 24h pH monitoring, oesophagoscopy and barium radiology. On this basis the causes of failure of the previous surgery were established as hiatal failure in 20 (65%), unrecognized oesophageal dysmotility in three (10%) and fundoplication failure (slipped and disrupted) in eight (25%). Contrary to standard recommendations for re-operation most re-operative surgery was performed transabdominally (94%). Complications occurred in 16%. RESULTS Review was undertaken at a mean of 21 months following surgery, and 91% of patients reported a good to excellent symptomatic outcome. CONCLUSIONS Transabdominal re-operative anti-reflux surgery has an acceptable complication rate and a surprisingly good symptomatic outcome in the medium term.
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Affiliation(s)
- J K Lim
- Department of Surgery, Concord, Strathfield Adventist Hospital, New South Wales, Australia
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34
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O'Sullivan GC, O'Brien MG. The surgery of complicated gastro-oesophageal reflux. Ir J Med Sci 1996; 165:193-9. [PMID: 8824026 DOI: 10.1007/bf02940250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Dallemagne B, Weerts JM, Jehaes C, Markiewicz S. Causes of failures of laparoscopic antireflux operations. Surg Endosc 1996; 10:305-10. [PMID: 8779064 DOI: 10.1007/bf00187377] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Three factors determine the successful outcome after an antireflux operation for gastroesophageal reflux disease (GERD): indication for surgery, choice of the operative procedure, and quality of the operation. Laparoscopic treatment has not changed these concepts. The factor most likely to have been modified is the technical quality of the operative procedure. We evaluated 26 patients presenting with failure after laparoscopic antireflux surgery to determine the causes. METHODS Nineteen patients came from our series of 503 laparoscopic antireflux procedures and seven patients were referred from other centers. Preoperative, peroperative, and postoperative data were retrospectively reviewed to analyze the responsible factor(s). RESULTS Nine patients presented with a sphincter mechanism failure to control reflux, 14 patients had severe dysphagia, 3 patients presented with severe epigastric pain. The first operation was a Nissen-Rossetti fundoplication in 17 patients. The technical quality of the operative procedure was the responsible factor in 22/26 patients. The choice of the type of operation was questionable in five patients. Eight patients underwent successful endoscopic treatment, reoperation was necessary in 10 patients. Four patients underwent medical therapy, and four patients had no treatment. CONCLUSIONS The laparoscopic Nissen-Rossetti fundoplication was associated with a higher rate of failures, in terms of recurrent disease or severe dysphagia. The use of this technique was related to the laparoscopic inexperience of the surgeon, leading to a wrong application of the original procedure. Partial posterior fundoplication and total fundoplication with division of the short gastric vessels are obviously associated with a better outcome, if the selection of the operation is based on a strict preoperative physiopathological evaluation of the disease.
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Affiliation(s)
- B Dallemagne
- Department de Chirurgie, Centre Hospitalier Saint Joseph-Espérance, Liege, Belgium
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Stein HJ, Feussner H, Siewert JR. Failure of antireflux surgery: causes and management strategies. Am J Surg 1996; 171:36-9; discussion 39-40. [PMID: 8554148 DOI: 10.1016/s0002-9610(99)80070-1] [Citation(s) in RCA: 111] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND With wider use of laparoscopic antireflux surgery, failed antireflux procedures are likely to become more common. METHODS The causes of failure, management strategies, and outcome were analyzed in a consecutive series of 105 patients with failed antireflux procedures. RESULTS Recurrent reflux was the most common primary symptom for referral (44.7%), followed by dysphagia (32.3%), and a combination of dysphagia and reflux (15.2%). The reasons for failure were disruption of the initial antireflux procedure (46%), a displaced repair (23%), a too-tight or too-long fundoplication (10%), an unrecognized motor disorder (9%), a paraesophageal or axial herniation (6%), or gastric denervation (6%). Revisional surgery was required in 71 patients, and 34 patients were managed conservatively. Intraoperative assessment during reoperation showed that technical errors during the initial procedure were responsible for failure in 40 of 71 patients. With an individual therapeutic approach, good results were achieved in 86% of patients undergoing revisional surgery. CONCLUSIONS Technical factors and inappropriate patient selection are the most common reasons for failure of antireflux surgery. An individual therapeutic approach based on an exact analysis of the reasons for failure of the initial procedure is essential for the successful management of these patients.
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Affiliation(s)
- H J Stein
- Department of Surgery, Technische Universität München, Germany
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DePaula AL, Hashiba K, Bafutto M, Machado CA. Laparoscopic reoperations after failed and complicated antireflux operations. Surg Endosc 1995; 9:681-6. [PMID: 7482163 DOI: 10.1007/bf00187939] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nineteen patients underwent laparoscopic reoperations for failed or complicated antireflux operations from a total of 248 patients with gastroesophageal reflux disease who had been operated on by this approach. Sixteen had been submitted to open surgery and three to laparoscopic surgery over a period ranging from 5 days to 31 years before the study. Three patients had been submitted to two open antireflux surgeries previously. Seventeen patients had recurrent reflux esophagitis after different types of surgeries, and two patients presented with gastric strangulation after fundoplication. The causes of recurrence were: slipped total fundoplications (3), disruption of total and partial fundoplications (6), too-tight total fundoplication (1), too-low (gastric) partial fundoplication (1), Allison procedure (1), partial fundoplication and paraesophageal hernia (2), and unknown (3). The laparoscopic approach was used in 18 patients and a laparoscopic-thoracoscopic approach in 1. The procedures included laparoscopic total fundoplications (11), partial fundoplications (4), transhiatal esophagectomy (1), Collis-Nissen (1), Roux-en-Y gastrectomy and thoracoscopic vagotomy (1), and intrathoracic fundoplication (1). One patient was converted to open surgery. Intraoperative complications included 1 pneumothorax, 1 gastric perforation, and 1 esophageal perforation during the introduction of a Maloney dilator. Mean operative time was 210 min, ranging from 140 to 320 min. Mean hospital stay was 3.1 days after treatment of failed operations and 22 days after treatment of complications. Postoperative complications included subcutaneous infection (1), gastric fistula (1), and liver hematoma (1). The results have been excellent and good in 84.3% of the patients after a mean follow-up of 13 months. We concluded that laparoscopic reoperations are technically feasible with good preliminary results provided that the mandatory expertise is available.
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Affiliation(s)
- A L DePaula
- Department of Surgery, Hospital Samaritano, Goiás, Brazil
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Affiliation(s)
- R M Bremner
- University of Southern California, Los Angeles, USA
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Abstract
Between 1978 and 1992, 61 patients were operated on for new or recurrent problems after antireflux surgery. Indications for reoperation were recurrent reflux in 50 patients (associated with dysphagia in 14), dysphagia alone in six and postprandial pain in five. At reoperation the cause of the problem was apparent as anatomical breakdown of the repair in 19 patients, gastric pull-through (slipped Nissen procedure) in 14 and paraoesophageal hernia in six. In 18 patients the cause of the symptoms was not readily apparent. Reoperation consisted of fundoplication alone in 27 patients, fundoplication with pyloroplasty in eight, fundoplication with proximal gastric vagotomy in four, a Collis-Nissen procedure in 11 (four also had pyloroplasty), a Roux-en-Y procedure in four, total gastrectomy in one and reduction of a paraoesophageal hernia in six. Of the 20 patients with some form of destruction of the gastric outlet six experienced troublesome dumping symptoms and in two this was severe. Two patients died from cardiac causes after surgery. Of the remaining 59 patients, 51 rated the procedure as successful. Repeat antireflux procedures can give results almost as good as those of primary antireflux surgery. However, pyloroplasty and gastric resection should be avoided if at all possible.
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Affiliation(s)
- N A Rieger
- Department of Surgery, Royal Adelaide Hospital, South Australia
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Luostarinen ME, Isolauri JO, Koskinen MO, Laitinen JO, Matikainen MJ, Lindholm TS. Refundoplication for recurrent gastroesophageal reflux. World J Surg 1993; 17:587-93; discussion 594. [PMID: 8273379 DOI: 10.1007/bf01659115] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Reoperation after a failed antireflux procedure is a surgical challenge. Many operative techniques have been proposed, but reports on systematic follow-up with endoscopy and esophageal function tests are few. The purpose of the present study was to evaluate the results of repeated fundoplication in cases of recurrent reflux, including assessment of esophageal function. Of the 18 cases of repeat fundoplication performed for recurrent reflux during 1970-1991 at Tampere University Hospital, 15 were evaluated a median of 18 (range 5-152) months after reoperation. Follow-up studies included endoscopy in all and esophageal function tests (esophageal 24-hour pH recording, manometry, and radionuclide transit) in 14 cases. All the patients had defective fundic wrap before reoperation, whereas at follow-up 12 of the 15 wraps were intact. Reflux symptoms were diminished in all 15. Six patients (40%), however, had objective recurrence of reflux (esophagitis or pathologic pH recording). Three of the recurrences were due to slipped fundic wrap, but the others were probably caused by impaired esophageal function. By repeat fundoplication the wrap could be repaired as reliably as in primary operation. Symptomatic outcome and objective results were reasonable. The results were, however, not as good as after primary operation, which was due to more impaired esophageal motility caused by prolonged reflux or repeated surgery (or both).
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Affiliation(s)
- M E Luostarinen
- Department of Clinical Medicine, University of Tampere, Finland
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