Gastrectomy as a Remedial Operation for Failed Fundoplication
Valerie A. Williams, Thomas J. Watson, Oliver Gellersen, Sebastian Feuerlein, Daniela Molena, Carolyn Jones, Lelan Sillin, Jeffrey H. Peters; Department of Surgery, Division of Thoracic/Foregut Surgery, University of Rochester Medical Center, Rochester, NY
The decision for, and choice of, a remedial antireflux procedure following 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 following re-operative 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. METHODS: The study population consisted of 37 patients who underwent either gastrectomy (n=12) with Roux-en-Y reconstruction or redo fundoplication (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 redo fundoplication groups, respectively (p=0.43). RESULTS: Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% v 4%, p=0.006) and of multiple prior fundoplications than those having redo fundoplication (75% v 24%, p=0.004). Mean symptom severity scores were improved significantly by both gastrectomy and redo fundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% v 50%, p=0.044). Overall patient satisfaction was similar in both groups (p=0.22). In-hospital morbidity was higher after gastrectomy than after redo fundoplication (67% v 16%, p=0.003) and new onset dumping developed in two gastrectomy patients. CONCLUSION: In select patients with severe GERD and multiple previous fundoplications, symptomatic outcome following gastrectomy is as good as or better than redo fundoplication. This occurs in association with higher morbidity and postoperative dumping. 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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