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Reoperative Surgery for Failed Fundoplication - a Complex Operation Best Done Well the First Time
Max Schumm*, Matthew J. Frelich, Kathleen L. Simon, Matthew I. Goldblatt, Andrew Kastenmeier, James R. Wallace, Jon Gould
Surgery - Division of General Surgery, Medical College of Wisconsin, Milwaukee, WI
Background: Laparoscopic Nissen fundoplication is the current gold standard for medically refractory gastroesophageal reflux disease. Published literature suggests that approximately 5% of patients eventually undergo reoperative surgery for a variety of indications. Our hypothesis is that as the number of previous antireflux operations increases in an individual patient, operative complexity and morbidity increases.
Methods: This study is a retrospective review of patients who underwent surgery for failed fundoplication at a single institution between January 2010 and September 2014. Procedures included reoperative fundoplication and conversions to Roux-en-Y Gastric Bypass (RYGB). Patients were selected for conversion to RYGB rather than reoperative fundoplication if their BMI was > 40 kg/m2, they suffered from clinically significant post-surgical gastroparesis, or they had undergone more than 2 previous attempts at fundoplication. Outcomes were evaluated up to one-year post-op. Complications were graded according to the Clavien-Dindo Classification of Surgical Complications. The Gastrointestinal Quality of Life (GIQLI) and GERD-Health Related Quality of Life (GERD-HRQL) questionnaires were administered preoperatively and at defined intervals following reoperative surgery.
Results: Surgery for failed fundoplication was required in 69 subjects over the study interval. There were 43 reoperative fundoplications (62%) and 26 conversions to RYGB (38%). Post-operative morbidity, length of stay, and operative time increased relative to the number of previous fundoplications performed. In all patients, GERD-HRQL scores significantly improved (mean 27.1 pre-op vs. 8.15 at 1 year post-op; p < 0.01). Similarly, GIQLI index was impaired prior to surgery and improved significantly following surgery. When evaluated independently based on the number of previous fundoplications, GIQLI increased significantly at each post-operative interval only in patients with just 1 previous fundoplication (table). Most complications within 30 days (50/102; 50%) were Clavien Classification Grade III (requiring surgical, endoscopic, or radiological intervention).
Conclusions: Reoperative antireflux surgery is a complex, high-stakes intervention for patients with previous failed fundoplication. The operative time, duration of hospital stay, complication rate, and need for conversion to RYGB increases with the number of previous fundoplication attempts. Gastrointestinal disease related quality of life likely declines with numerous attempts at reoperative fundoplication. For these reasons, we believe that patients should be referred to surgeons with significant experience in reoperative antireflux surgery after the primary fundoplication fails the first time.
| Number of Previous Fundoplications | | Variable | 1 (n=49) | 2 (n=15) | 3 (n=5) | p-value | | % RYGB | 14 (29%) | 7 (47%) | 5 (100%) | <0.01 | | Median LOS (days) | 2 (1-12) | 3 (2-10) | 5 (2-31) | <0.01 | | Mean OR Time (mins) | 219.3 (77.4) | 272.6 (57.3) | 332.4 (90.7) | <0.01 | | Gastroparesis | 3 (6.1%) | 6 (40%) | 2 (40%) | <0.01 | | ≥ 1 Complication | 25 (51%) | 11 (73%) | 5 (100%) | 0.04 | | GIQLI pre-op | 70.4 (25.3) | 65.6 (22.0) | 64.9 (14.0) | - | | GIQLI post-op | *92.3 (26.0) | 78.1 (32.8) | 72.5 (0.71) | - |
Reported as mean ± (SD) using two tailed t-Test, ANOVA or 2x3 Fisher Test (*p<0.05).
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