Re-operative anti-reflux surgery: When and How?

Lee L. Swanstrom, MDDivision of Minimally Invasive Surgery

Legacy Health System

Dept of Surgery, OR Health Sciences University

Results: Laparoscopic Nissen - Results: Laparoscopic Nissen - 10/91 to 9/9910/91 to 9/99

• 644 primary Nissens for GERD

• age = 52 (14 - 87)• 64% males• OR time 136 min (52 - 235)• LOS 1.6 days (0 - 17)• Mortality = 0• Complications 11%

• 599 good to excellent results (93%)

• early failure = 12 (2%)• reoperation = 32 (5%)• on medication = 103

(16%)• 241 with objective f/u:

– 38 (16%) had evidence of continued reflux

Swanstrom, Jobe; Surgical Endosc; 1999

What is a failed fundoplication?

• Continued use of peptic medication?• Heartburn/Reflux?• Side effects related to surgery?

– Dysphagia– Gasbloat– Nausea/diarrhea

• Objective test results?– 24 hr pH– EGD/UGI– manometry

Failure

• Residual or recurrent symptoms

• Wrap herniation or disruption

• Abnormal 24 hr. pH

• Non-dilatable dysphagia (worse than before)

Not…Not…

• Side effects

• Use of medications

• Symptoms alone

• Do symptoms mean there is reflux?– 2/3 of patients c/o post op GERD sx have

normal 24 hr pH– 9% of patients with no symptoms have a pos.

24 hr pH.

Khajanchee YS, “Postoperative Symptoms and failure following antireflux surgery” Arch Surg, 2002. 137(9):1008-14.

Risk of recurrence

• Type V (recurrent, postoperative)

• Type IV (giant, multivisceral)• Type III (combined)• Type I (sliding)• Type II (rolling)

– Fundus herniated into mediastinum

– GE junction in normal position

Low

High

Modes of Failure After ARSModes of Failure After ARS

• h

Gastric retraction without adequate esophageal length

GEJ retracted below diaphragm under tension

GEJ retracted below diaphragm under tension

Malpositioning of the fundoplication

Why do fundoplications fail?

Failed fundoplication

Wrong surgeon Wrong surgery

Wrong patientTechnical error

“Patients with substantial psychological overlay cannot be

expected to do as well with standard therapy…”

• Avoid the crazed, bulemic, voluntary wretching, aerophagic patients…

Mechanical problems:

• failures are due to:–wrap herniation*–wrap disruption*–malpositioned wrap–reflux through intact wrap

*mostly as a result of a repair under tension

Reasons for failure

Repairs under tension!Repairs under tension!

• Torsion = divide the short gastricsTorsion = divide the short gastrics

• Wrap = loose fundoplicationWrap = loose fundoplication

• Axial = beware the short esophagus!Axial = beware the short esophagus!

Who should be considered for another antireflux surgery?

• Patients with daily symptoms (heartburn/dysphagia) requiring chronic medical treatment

• patients who have complications from GERD coming back

• Patients with objective confirmation of failure• Patients with a defined mechanical or

physiologic reason for failure

An extensive preoperative evaluation is critical for the difficult patient• Complete medical evaluation• Comprehensive esophageal physiology testing

– UGI– endoscopy– motility testing– 24 hr pH test– gastric emptying study

• Don’t hesitate to say “No”

Motility for:• esophageal length•Esophageal function•LES function

pH for:•Reflux?•Correlation without•Symptom correlation

Technique

setup

adhesiolysis

L crural exposure

R crus

Retro-gastric adhesions

Slipped Nissen

Type II dissection

Transhiatal dissection will achieve esophageal mobilization in the majority of cases

Shortened esophagus on preop imaging

Laparoscopic approach

Standard dissection to achieve 2 cm of intraabdominal length

Extensive Type II Fundoplication

dissection (Nissen)

No Almost Yes

Collis gastroplasty Hill procedure

no yes

Check for short esophagus

• If short, do a lengthening procedure

Thoracoscopic/Laparoscopic Approach

Thoracoscopic/Laparoscopic Approach

Disassemble wrap

Completely undone

Appropriate wrap placement

Endoscopic adjustment

Original fixationOriginal fixation

Complete fundoplication

Progressive failure

01234

initialsurgery

2ndsurgery

3rdsurg

4th surg

Visick scoreVisick score

***

***

* 209 patients** 82 patients*** 21 patients

Problem prevention:• Careful attention to patient symptoms and

complaints• A thorough and complete evaluation

– EGD– Motility– 24 hr pH– Gastric emptying– Bernstein– Bilitek– Impedance testing

• No hesitation to say “no”!

On all patients

Avoid wrap tightness!

• Short, floppy fundoplication

• Use a large dilator

Avoid axial tension!

• Recognize and treat (or avoid) the “short esophagus”

Reoperative ARS

• Know ahead of time what went wrong• Tell the patient the bad news• Prep for a Collis• Have a flexible endoscope in the room• sharp, precise dissection• Completely take down the old repair• Check for leaks• Be patient

Thank you