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Background: Re-do fundoplication (RF) is reported to improve quality of life and patient satisfaction in more than 80% of patients with failed fundoplication. However, the role of re-do fundoplication in elderly (> 65 years) patients is not well reported in the literature. The aim of this study was to assess long term outcomes of RF in elderly patients.
Methods: A retrospective review of patients ≥ 65 years of age who underwent RF at a single institution by a single surgeon for recurrent GERD (2004 - 2008) was performed. Patients were contacted at 1, 3, 5, 7 and 10 year intervals after surgery and administered a standard symptom questionnaire. Symptom assessment was done using a 0-3 scale, and grade 2-3 symptoms considered to be significant. Patients were also asked to grade their satisfaction with surgery on a scale of 1-10.
Results: Of 114 patients undergoing RF during the period, 31 elderly patients (27%) were included in the study group. The mean age was 72 years (65 - 85 years) with 22 (70%) women. Heartburn and dysphagia were the most common indications for a re-operative procedure with 15 patients (48 %) and 14 patients (45 %) patients, respectively. Recurrent hiatal hernia was noted in 17 (55%) patients. Laparoscopic Nissen fundoplication was the original surgery in 23 (75%) patients. Toupet fundoplication was the most common re-operative procedure (17 patients - 55%). The majority (65 %) of RF were completed laparoscopically. Additionally, there were 4 laparoscopic to open surgery conversions and 4 thoracic procedures. Intra-operative viscus perforation and solid organ injury were identified in 26% (8 patients) and 10% (3 patients), respectively. Major post-operative complications were noted in 10 patients (2 arrhythmia, 3 post-operative leaks, 1 post-operative bleeding and 4 pulmonary). One patient required return to the operating room on POD#3 for a leak. Median ICU and total hospital stay were 6 (range 1-45) days and 6 (range 2-55) days, respectively. There was no 30 day or in-hospital mortality. Greater than five year follow-up was available for 17 patients (mean of 72 months). Four patients died in the interim from unrelated causes. Moderate to severe symptoms were reported by a total of 5 patients (29%) (3 heartburn, 2 regurgitation, 1 dysphagia and chest pain in none). Seven patients were on acid suppressive medications. Excellent satisfaction (grade 8-10) was reported by 13 (77 %) patients and good (grade 6-7) by 3 (18%) patients. The majority (88%) of patients stated that they would recommend the procedure to a friend if needed.
Conclusion: RF can be safely performed laparoscopically in the majority of patients ≥ 65 years of age for recurrent GERD after initial fundoplication. The long-term post-operative outcomes in this subset of patients are satisfactory though associated with high peri-operative morbidity.