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PRIMARY AND REOPERATIVE ANTIREFLUX SURGERY: OUTCOMES AND LESSONS LEARNED
Saurabh Singhal*1,2, Takahiro Masuda1,2, Sumeet Mittal1,2
1General Surgery, Creighton University School of Medicine, Omaha, NE; 2Norton Thoracic Institute, St. Joseph's Hospital & Medical Center, Phoenix, AZ

Introduction
Laparoscopic fundoplication is gold-standard for the treatment of gastro-esophageal reflux disease. A subset of patients may require one or more reoperative interventions. The outcome purportedly worsens with each sequential intervention. Aim of this study was to compare outcomes following primary antireflux surgery (ARS), and first and each subsequent reoperative ARS.
Methods
After IRB approval, prospectively maintained database was queried to identify patients who underwent ARS between Dec-2003 and May-2016. Patients who underwent primary surgery for intra-thoracic stomach or reoperative procedures requiring esophageal resection were excluded. Patients were categorized as: A-Primary ARS, B- 1st Reoperative ARS, C- 2nd Reoperative ARS, and D- ≥3rd Reoperative ARS. Follow-up patient foregut symptom and satisfaction questionnaire was administered at regular intervals. Symptom severity score of ≥2 (0-3) was considered as significant symptom. Satisfaction score of ≥8 (0-10) was considered as excellent satisfaction. Groups were compared for baseline patient characteristics, peri-operative and post-operative outcomes and long-term follow-up.
Results
Of 1151 ARS done during the study period, 940 met inclusion criteria (A-545, B-302, C-80, D-13). Groups were comparable for age, sex, BMI, and prevalence of Barrett’s. Heartburn was the most common pre-operative symptom in A while Dysphagia was more common in reoperative groups. Pre-operative symptom score ≥2 (29% vs 37% vs 39% vs 67%), dysmotility (37% vs 43% vs 59% vs 69%), and short esophagus (2% vs 6% vs 27% vs 58%) were increasingly more common from A to D (p<0.05).
Need for open approach (0.4% vs 9% vs 25% vs 39%), operative time (112 vs 190 vs 230 vs 237 min) and blood loss (54 vs 186 vs 282 vs 202 ml) increased from A to D (p<0.05). RNY reconstruction was utilized as the antireflux procedure in increasing frequency (3% vs 29% vs 68% vs 62%, p<0.05). Inability to identify and preserve both Vagus nerves (2% vs 19% vs 33% vs 54%), visceral perforation (2% vs 20% vs 36% vs 23%), post-operative leak (0.2% vs 2% vs 6% vs 8%) and morbidity (Clavien-Dindo≥III) (2% vs 10% vs 14% vs 39%) increased from A to D (p<0.05).
A mean follow-up of 36.1 months was available for 73.6% patients and was comparable between the groups. Proportion of patients reporting no significant symptoms (77% vs 68% vs 46% vs 44%), excellent satisfaction (91% vs 76% vs 49% vs 33%) and likelihood of recommendation to a friend (90% vs 87% vs 69% vs 33%) progressively declined with each successive intervention (p<0.05).
Conclusion
Primary ARS is associated with satisfactory outcomes. There is increasing intraoperative and postoperative complications along with worsening patient-centered outcomes with each subsequent reoperative intervention.


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