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A Large, Single-Surgeon Experience With Laparoscopic Redo Fundoplication: Operative Technique and Long-Term Outcomes
Roberto a. Estrada GóMez*, Wolfgang Gaertner, MartíN Vega De JesúS, Jorge G. ObregóN MéNdez, Alfonso Arias GutiéRrez, Beatriz De Rienzo, Cesar Decanini
Minimally Invasive Surgery, ABC Medical Center, Mexico City, Mexico
BACKGROUND: Gastroesophageal reflux (GER) is one of the most common gastrointestinal complaints worldwide with more than 24,000 anti-reflux operations being performed annually in the US. Approximately 10% of these patients require reoperation. The aim of this study was to review the outcomes of patients undergoing laparoscopic redo fundoplication.
METHODS: Retrospective review of patients undergoing laparoscopic redo fundoplication from 1999 to 2011 by a single surgeon.
RESULTS: 135 patients (70 men, mean age 42 [range, 26-68] years) underwent laparoscopic redo fundoplication following a standardized technique (figure). Operative indications included dysphagia (n=67, 50%), recurrent GER (n=62, 46%), and bubble syndrome (n=6, 4%). Median time to reintervention was 25 months. Median operative time was 120 (range, 45-270) minutes, intraoperative complication rate was 11%, and conversion rate was 4% (n=6). All patients underwent intraoperative endoscopy. The most common cause of operative failure was proximal migration of the gastroesophageal junction and fundoplication (41.5%). 77% underwent a redo 360° fundoplication and 23% a 270° wrap. Median hospital stay was 3 (range, 2-8) days. At a median follow-up of 28 months, 6% of patients were receiving proton-pump inhibitors; and no dysphagia or symptoms of bubble syndrome or delayed gastric emptying were reported. No correlation was found between preoperative symptoms and type of operative failure (table).
CONCLUSIONS: Laparoscopic redo fundoplication is a feasible, safe, and effective treatment for persistent and recurrent symptoms after primary anti-reflux surgery. Following a standardized operative technique with intraoperative endoscopy, we have shown good results at long-term follow-up.
Essential Operative Steps
| 1. Dissection between the undersurface of the liver and anterior surface of the fundoplication to identify the right crus first. | | 2. Circumferential dissection of the esophageal hiatus starting posteriorly. | | 3. Full takedown of the fundoplication. | | 4. Obtain a minimum of 4-5cm of intra-abdominal esophagus. | | 5. Verify full transection of the sort gastric vessels. | | 6. Crural closure and redo fundoplication over a 60Fr boogie. | | 7. Intraoperative endoscopy to assess the configuration of the new fundoplication and rule-out gastroesophageal injury. | | 8. Bilateral fixation of the fundoplication to the crura to prevent migration, rotation, and herniation. | |
Findings | Age (years) | 42 | | Gender (M/F) | 70/65 | | Operative indication: Dysphagia Recurrent GE reflux | 67 (50%) 62 (46%) | | Median operative time (minutes) | 120 (45-270) | | Conversion rate | 6 (4.7%) | | Operative failure mechanism* Proximal migration of the gastroesophageal junction and fundoplication (IA) (II) Paraesophageal hernia with intra-abdominal GE junction and fundoplication "Fundoplication" constructed with the gastric body (III) Proximal migration of the gastroesophageal junction with an intra-abdominal fundoplication (IB) | 41.5% 28% 21% 9% | | Complications Left pneumothorax Gastric perforation Right pneumothorax Splenic laceration | 15 (11%) 9 3 2 1 | | Median time to reoperation (months | 25 (0.07-106) |
GE: gastroesophageal; *according to the Horgan classification
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