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

Re-operative anti-reflux surgery: When and How?. Lee L. Swanstrom, MD Division of Minimally Invasive Surgery Legacy Health System Dept of Surgery, OR Health Sciences University. 644 primary Nissens for GERD age = 52 (14 - 87) 64% males OR time 136 min (52 - 235) LOS 1.6 days (0 - 17)

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

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  1. Re-operative anti-reflux surgery: When and How? Lee L. Swanstrom, MD Division of Minimally Invasive Surgery Legacy Health System Dept of Surgery, OR Health Sciences University

  2. 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 Results: Laparoscopic Nissen - 10/91 to 9/99 Swanstrom, Jobe; Surgical Endosc; 1999

  3. 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

  4. Failure • Residual or recurrent symptoms • Wrap herniation or disruption • Abnormal 24 hr. pH • Non-dilatable dysphagia (worse than before)

  5. Not… • Side effects • Use of medications • Symptoms alone

  6. 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.

  7. 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 High Low

  8. Modes of Failure After ARS • h GEJ retracted below diaphragm under tension Gastric retraction without adequate esophageal length Malpositioning of the fundoplication GEJ retracted below diaphragm under tension

  9. Why do fundoplications fail?

  10. Wrong surgery Wrong surgeon Failed fundoplication Wrong patient Technical error

  11. “Patients with substantial psychological overlay cannot be expected to do as well with standard therapy…” • Avoid the crazed, bulemic, voluntary wretching, aerophagic patients…

  12. 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

  13. Reasons for failure Repairs under tension! • Torsion = divide the short gastrics • Wrap = loose fundoplication • Axial = beware the short esophagus!

  14. 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

  15. 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”

  16. pH for: • Reflux? • Correlation without • Symptom correlation • Motility for: • esophageal length • Esophageal function • LES function

  17. Technique

  18. setup

  19. adhesiolysis

  20. L crural exposure

  21. R crus

  22. Retro-gastric adhesions

  23. Slipped Nissen

  24. Type II dissection

  25. Transhiatal dissection will achieve esophageal mobilization in the majority of cases

  26. 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

  27. Check for short esophagus • If short, do a lengthening procedure

  28. Thoracoscopic/Laparoscopic Approach

  29. Thoracoscopic/Laparoscopic Approach

  30. Disassemble wrap

  31. Completely undone

  32. Appropriate wrap placement

  33. Endoscopic adjustment

  34. Original fixation

  35. Complete fundoplication

  36. Progressive failure *** ** * * 209 patients ** 82 patients *** 21 patients

  37. 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

  38. Avoid wrap tightness! • Short, floppy fundoplication • Use a large dilator

  39. Avoid axial tension! • Recognize and treat (or avoid) the “short esophagus”

  40. 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

  41. Thank you

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