Introduction: Laparoscopic antireflux surgery is well established since more than 15 years. Redo-antireflux surgery with laparoscopic and open access is following this development, since 4-5% of failures need operative revision. The purpose of this study is the analysis of a possible difference between a first time failure and redo-surgery versus multiple failures and multiple Redo-surgery.
Methods: In a center with experience of approximately 80 primary laparoscopic antireflux cases per year in a time period of 10 years 104 consecutive redo operations were performed and all involved perioperative details were prospectively documented. There were 61 males and 43 females with a mean age of 48 years (17-85). Diagnostic work up consisted of history and physical examination, endoscopy, video barium sandwich study, esophageal manometry, 24 pH monitoring and in selectve cases bilirubine monitoring and scintgraphy. Operative techniques in Redo surgery consisted of laparoscopic adhesiolysis, esophageal mobilisation, hiatoplasty, fundoplication full or partial, in case of short esophagus a lengthening by Collis plasty and in cases of massive shortage and/or destruction, strictures and scaring of the gastroesophageal junction a resection and jejunal interposition or gastrectomy and Roux-en-Y pouch reconstruction.All details were prospectively documented. Follow up was performed within the first year. Quality of Life was assessed by the Gastrointestinal Quality of Life Inedx GIQLI.
Results: Redo-surgery was performed in 59 first failure cases(groupFR) and in 45 multiple failure cases(groupMR). Recurrent reflux was the major problem in the first failure cases (81%) compared to 53% in the multiple failure cases. Dysphagia was similar frequent in both groups. However pain and vomiting was significant different (FR:6%; MR:36%). Major reason for failures were in both groups migration (FR:53%; MR: 40%). In the MR group paraesophageal herniation and scaring ("frozen Hiatus") was an important reason for pain and vomiting.Standard Nissen and Toupet fundoplication in the laparoscopic technique was performed in 93% in the FR group and only in 53% in the MR group. Collis-plasty and resections were performed in 46% of the MR group. Outcame in Quality of life showed preop/postop 1year: FR in 14%<100 (normal 120) MR in 29%<100.
Conclusion: Multiple failures of laparoscopic antireflux procedures are difficult to manage. Outcome can be worse than first time redo-surgery. Pain and vomiting are major symptoms , which require revision. Therefore revision in cases with multiple failure should be performed in specialized centers.