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Ann Thorac Surg 2006;81:2050-2054
© 2006 The Society of Thoracic Surgeons

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Original article: General thoracic

Failed Antireflux Surgery: Results After Reoperation

^a Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
^b Division of BioStatistics, Mayo Clinic College of Medicine, Rochester, Minnesota

Accepted for publication January 4, 2006.

^_* Address correspondence to Dr Deschamps, Division of General Thoracic Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905 (Email: deschamps.claude{at}mayo.edu).

Presented at the Fifty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 10–12, 2005.

	Abstract

Top Abstract Introduction Material and Methods Results Comment Discussion References

 
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.

	Introduction

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Prior to the introduction of laparoscopic repair, reoperation for failed open repair was associated with a success rate ranging from 42% to 94% [1–11]. Today only a few reports have evaluated the efficacy of reoperation for failed antireflux surgery in the laparoscopic era. The purpose of this report is to review our recent experience with reoperation for recurrent gastroesophageal reflux disease and or recurrent hiatal hernia.

	Material and Methods

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All patients who underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease or recurrent hiatal hernia at the Mayo Clinic in Rochester, Minnesota, between July 1, 1995 and April 1, 2004 were reviewed. There were 126 patients; however, 2 patients declined research participation and were excluded from further analysis. The medical records of the remaining 124 patients were analyzed for age, gender, symptoms, diagnostic evaluation, indications for operation, operative procedure, morbidity and mortality, and factors affecting functional outcome. Data were acquired from visits to the outpatient clinic. Functional status was considered excellent if the patient was eating a general diet without preoperative symptoms or without requiring medication. Functional status was good if symptoms were minimal and if medication on a regular basis or dilation was not required. Functional status was fair if symptoms were improved by medication on a regular basis or dilation was required. Functional status was poor if symptoms were unchanged or worse, or if the patient required reoperation.

Associations between functional results at last follow-up and measured variables were assessed, dichotomizing functional outcome as excellent or good versus fair or poor. Associations with continuous variables were assessed using two sample t tests [12] or the Wilcoxon rank-sum tests [13] as appropriate. Nominal categorical variables were compared using ² tests [14] or Fisher's exact tests [15–17] as appropriate. An overall hazard of reoperation and 95% confidence interval was estimated using the Kaplan-Meier method [18]. All statistical tests were two-sided and p values less than 0.05 were considered significant. The Mayo Clinic College of Medicine Institutional Review Board granted approval for this study. All patients in the study gave consent for research participation. Results were compared with a previous historical series published by our group [1].

Clinical Findings
There were 71 women (57.2%) and 53 men (44.9%). Median age at the time of reoperation was 53 years and ranged from 19 to 83 years. One hundred patients had a single prior antireflux operation, 20 had two operations, and 4 had three. A laparoscopic approach was done in 76 patients, laparotomy in 48, and left thoracotomy in 28. The previous antireflux procedures included 130 Nissen fundoplications, seven Belsey fundoplications, three anatomical hernia repairs, two Hill gastropexies, two Angelchik prostheses, and eight unknown. Related procedures included a cut Collis gastroplasty in 4 patients, uncut Collis gastroplasty in 2, and removal of an Angelchik prosthesis, Thal patch, antrectomy and Billroth II reconstruction, Roux en Y gastro-jejunostomy, and myotomy in 1 each, respectively.

The median time between the most recent antireflux operation and reoperation was 28 months and ranged from 1.2 to 368.1 months. Indication for reoperation was recurrent gastroesophageal reflux symptoms in 67 patients (54.0%) and esophageal obstruction in 57 (46.0%). Pyrosis was present in 34 patients (27.4%), dysphagia in 57 (46.0%), pain in 49 (39.5%), regurgitation in 37 (29.8%), and aspiration in 27 (21.8%). Esophageal dilation had been performed at least once in 23 patients (18.5%) prior to reoperation. Weight loss was observed in 26 patients (median, 11.5kg; range, 10 to 50 kg).

Barium roentgenographic esophageal examination was performed in 95 patients (76.6%), esophagoscopy in 118 (95.0%), esophageal manometry in 67 (54.0%), and a pH study in 27 (22.0%). Barium swallow demonstrated a hiatal hernia in 59 patients (47.6%), stricture in 17 (13.7%), reflux in 20 (16.1%), displaced fundoplication in 9 (7.3%), loose or disrupted fundoplication in 5 (4.0%), and retained gastric food in 1 (1.0%). Esophagoscopy demonstrated a hiatal hernia in 50 patients, esophagitis in 39 (31.0%), and stricture in 14 (11.0%). Barrett's disease was documented histologically in 19 patients (15%), 7 with low grade dysplasia (6.0%). The previous fundoplication was found to be disrupted in 7 patients (6.0%) and displaced in 6 (5.0%).

Esophageal manometry demonstrated that the lower esophageal sphincter was hypotensive in 17 patients (13.7%) and hypertensive in 4 (3.2%). Low amplitude peristalsis was also present in the body of the esophagus in 10 patients (8.0%). Twenty patients (16.1%) had a positive pH study.

The reoperative approach was a thoracotomy in 83 patients (67.0%), laparotomy in 36 (29.0%), laparoscopy in 4 (3.0%), and thoracoabdominal in 1 (1.0%). Operative findings included a recurrent hernia in 80 patients (64.5%), a disrupted fundoplication in 40 (32.3%), a perigastric fundoplication in 18 (14.5%), and a tight fundoplication or hiatal closure in 10 (8.0%). A Nissen fundoplication was performed in 86 patients (69.4%), Belsey fundoplication in 31 (25.0%), truncal vagotomy and antrectomy with Roux-en-Y gastro-jejunostomy in 2 (1.6%), partial posterior fundoplication and anatomical repair in 2 each (1.6%), and partial anterior fundoplication in 1 (1.0%). An uncut Collis gastroplasty was added to the fundoplication in 35 patients, a cut Collis gastroplasty in 6, a pyloroplasty in 10, and a wedge gastroplasty in 3. Median operative time was 213.5 minutes and ranged from 94 to 420 minutes.

	Results

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Complications occurred in 27 patients (21.8%) (Table 1). There was no operative death. Median hospitalization was 6 days and ranged from 5 to 58 days. Follow-up ranged from 10 days to 10 years (median, 9.7 months). Overall, 114 patients (87.8%) were improved. Functional results were classified as excellent in 69 patients (55.7%), good in 19 (15.3%), fair in 26 (21.0%) and poor in 10 (8.0%) (Table 2). Six patients (3.2%) required another operation. Indications for further surgery were a recurrent hernia in 5 patients and gastric stasis in 1. The cumulative probability of reoperation at 4 years was 4.2%, (95% confidence interval, 0% to 8.4%).

	Comment

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Laparoscopic fundoplication has become a well-established approach for gastroesophageal reflux disease [19]. As experience was gained, this procedure also expanded into repair of large paraesophageal hernias [20] and recurrent diaphragmatic hernias [21]. Today the failure after laparoscopic repair has become an increasingly common clinical condition [22–24] and in our experience the rate of failed antireflux surgery has more than doubled during the past decade (Table 3).

The spectrum of failure after antireflux surgery ranges from large, recurrent hiatal hernia with obstructive symptoms to recurrent reflux symptoms without significant anatomic abnormalities. Understanding what led to the failure is critical to the success of a possible reoperation. Diagnostic evaluation includes barium swallow examination, esophagogastroduodenoscopy, esophageal manometry, esophageal pH monitoring, and assessment of gastric emptying. Approximately half of our current patients were reoperated on for recurrent reflux symptoms, and the remainder of the patients for obstructive symptoms. As with the initial antireflux operation, a clear indication for reoperation for recurrent gastrointestinal reflux disease are symptoms that fail to respond to strict medical management. Less clear indications are recurrent symptoms in the absence of significant anatomical abnormalities that can be medically managed. For example, controversy exists as to whether patients with small recurrent hernias who have symptoms that are readily controlled should be reoperated on at all [25].

The type of initial operation, the current anatomy of the esophagogastric junction, and the presence and extent of endoscopic esophagitis all influence the reoperative approach [26]. In addition, the presence of significant obesity, esophageal shortening, and massive herniation of the stomach are additional factors to take into consideration [1]. During the years, thoracotomy has been our preferred approach for reoperation because it allows optimal exposure of the thoracic portion of the esophagus and can be extended into the abdomen to improve exposure if necessary. However, we have noted an increased shift toward the open abdominal approach during the past decade (Table 3), most likely because of increasing comfort from experience gained with our laparoscopic practice. Nonetheless, an open approach may still be preferable in the elderly, in a patient without a hernia, or if a concomitant gastric emptying procedure is also deemed necessary in a patient. Similar to surgeons who perform only open surgery, the laparoscopic surgeons are discovering that reoperative laparoscopic surgery is significantly more difficult with both a higher conversion rate and a higher morbidity rate than with primary laparoscopic fundoplication [24]. Although most surgeons would agree that reoperative laparoscopy for failed fundoplication by an experienced laparoscopic surgeon is safe and effective, most reported series are small, retrospective reviews of a single surgeon's personal experience [24].

At reoperation, the most frequent finding in our patients was recurrent hiatal hernia (65%), followed by disrupted fundoplication (32%), perigastric fundoplication (14.5%), and a tight fundoplication and hiatal closure (10%). These findings are similar to those reported in our previous study, except for a greater incidence (10% vs 32%) of patients with disrupted fundoplication (Table 4).

The key to a successful outcome includes both proper patient selection and careful operating technique [27]. The goals of reoperation should be identical to that of the primary procedure, namely: (1) complete reduction of an associated hiatal hernia if present, (2) establishment of an adequate intraabdominal length of esophagus, (3) appropriate crural closure, and (4) recreating the competence of the lower esophageal sphincter with fundoplication. In addition, it is almost always necessary to completely take down the previous repair to adequately define the anatomy of the esophagogastric junction. Limitations of our study include the assessment of postoperative morbidity, which was varied, and the generally short follow-up time.

We conclude that reoperation for failed antireflux surgery is safe and effective. Functional results are excellent or good in a majority of patients. Results of reoperation were not significantly associated with the type of reoperation or whether the previous approach was laparoscopic or open.

	Discussion

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DR JAMES LUKETICH (Pittsburgh, PA): A very nice presentation and excellent results. I wondered if you could explain a little bit more about the functional outcomes and how you assess what is a "good" outcome. Did you use any outcomes tools, such as the SF 36 or the Heartburn related Quality of Life questionnaires to give a more objective analysis of your outcomes? Also, you mentioned this did not include resections. How many patients underwent esophagectomy for failed Nissens during this time frame?

DR OHNMACHT: Our classification of functional outcome was a four-tiered system: excellent and good, fair and poor. It ranged from excellent, in which patients were free of symptomatology and were free of medications postoperatively at the time of follow-up; good and fair patients were ranked on symptomatology and need for medication; and poor results were patients who required a reoperation or had no improvement of their symptomatology.

In terms of patients who went straight to esophageal resection upon their referral and presentation, these were excluded from this study, but the number is relatively small.

DR LUKETICH: Did you consider using any detailed quality of life outcomes such as the heartburn-related quality of life or SF-36?

DR OHNMACHT: That was not used in this study but is now part of our next outcome study.

DR DANIEL L. MILLER (Atlanta, GA): I have one question. Ten percent of your patients had associated dysmotility, hypertensive lower esophageal sphincter, or aperistalsis, but in your slide of additional procedures none of your patients had a myotomy performed to address these problems. In the cases that we are asked to see for redo laparoscopic procedures, a common problem has been the failure to address or to diagnose associated motility problems at the time of the original procedure. From your data it seems that you were aware of the dysmotility problems, but did not address them. I was wondering in your patients who had poor outcome were these the patients who had uncorrected dysmotility issues? Thank you.

DR OHNMACHT: For the purpose of this study, any patient with a primary motility disorder would have been excluded.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Galen A. Ohnmacht Claude Deschamps Stephen D. Cassivi Francis C. Nichols, III Mark S. Allen Peter C. Pairolero Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ohnmacht, G. A. Articles by Pairolero, P. C. Search for Related Content PubMed PubMed Citation Articles by Ohnmacht, G. A. Articles by Pairolero, P. C. Related Collections Esophagus - other