"We can conclude that laparoscopic revision antireflux surgery ... is feasible and safe but subject to somewhat greater risk of conversion."
Transmediastinal migration of the wrap or a recurrent hiatal hernia (64%) were the most common causes of failure of the prior antireflux operation. Esophageal shortening was noted in 43% of patients, and a defect in the crural repair was identified in 4.4%. The most common procedure during reoperation was a Nissen fundoplication with or without a Collis gastroplasty. Nearly all of the redo procedures (93%) were done with a minimally invasive approach. There were eight conversions to open surgery due to extensive adhesions or a recognized intraoperative perforation, Dr. Awais and his associates reported.
Major complications included postoperative leaks in 3.3%; atrial fibrillation in 2%; and bleeding, pulmonary embolism, and Clostridium difficile colitis, each in less than 1%. Reexploration was required in 1.4%, for complications related to leak or bleeding. There was no perioperative mortality. Length of stay ranged from 1 to 75 days (median 3 days).
During follow-up of up to 14.5 years (median 3.3 years), 11.3% had a failure of the redo operation, requiring surgical intervention. An esophagectomy was required in 4 patients. The estimated probability of freedom from failure was 95% at 1 year, 93% at 2 years, and 84% at 5 years. Age and partial fundoplication were significantly associated with failure of the redo operation, and there was a trend for multiple redo operations to be associated with failure, Dr. Awais and his associates said.
Dysphagia decreased significantly after the redo procedure in 135 patients, with dysphagia scores declining from 2.7 to 1.4. Scores on the GERD-Health Related Quality of Life questionnaire, available in 186 patients, were excellent in 52% and satisfactory in 33%.
"Redo surgery after failed fundoplication is a complex operation, and a comprehensive evaluation should be completed prior to performing the procedure. ... Thoracic surgeons with significant laparoscopic and open esophageal surgical experience can perform minimally invasive complex redo esophageal antireflux procedures safely, with excellent to satisfactory results possible in more than 80% of patients using minimally invasive techniques at an experienced center," Dr. Awais and his associates concluded.
Both Dr. Symons and Dr. Awais stated that they had no disclosures.