SSAT - ROUX-EN-Y RECONSTRUCTION GIVES BETTER SYMPTOM RELIEF THAN REDO FUNDOPLICATION IN A SUBSET OF PATIENTS UNDERGOING REOPERATIVE ANTIREFLUX SURGERY

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ROUX-EN-Y RECONSTRUCTION GIVES BETTER SYMPTOM RELIEF THAN REDO FUNDOPLICATION IN A SUBSET OF PATIENTS UNDERGOING REOPERATIVE ANTIREFLUX SURGERY
Saurabh Singhal^*, Takahiro Masuda, Sumeet Mittal
Norton thoracic institute, St. Joseph's Hospital & Medical Center , Phoenix, AZ

Introduction
A subset of patients may require one or more reoperative interventions following primary antireflux surgery (ARS). Roux-en-Y reconstruction (RNY) may be an effective alternative to redo fundoplication (RF) in some patients. Aim of this study was to compare perioperative and postoperative outcomes and long-term follow-up following RF vs. RNY.
Methods
After IRB approval, prospectively maintained database was queried to identify reoperative ARS done between Dec-2003 and May-2016. Patients requiring esophageal resection were excluded. Risk assessment was scored from 0-6 based on the number of pre-operative risk factors (viz. BMI≥35, ≥2 previous ARS, previous mesh at hiatus, dysmotility on manometry, short esophagus, and delayed gastric emptying). Score≥3 was considered high risk. Follow-up patient foregut symptom and satisfaction questionnaire was administered at regular intervals. Symptom severity score of ≥2 (0-3) was considered significant symptom. Satisfaction score (Scale 0-10) of ≥8 was considered excellent and 5-7 as good satisfaction. Patient characteristics, peri-operative and post-operative outcomes and long-term follow-up were compared between the groups.
Results
Of 408 reoperative ARS done during the study period, 395 met inclusion criteria (246 RF, 149 RNY). Cohorts were comparable for preoperative characteristics except for higher BMI and high prevalence of dysmotility in RNY (p<0.05). RNY had higher mean risk score (2.13 vs 1.11, p<0.05).
RNY patients were more likely to require open approach (28% vs 4%), longer operative time (234 min vs 178 min) and hospital stay (7.7 days vs 5.6 days). Inability to identify or preserve both Vagus nerves (RF-11%, RNY-42%) and visceral perforation (RF-19%, RNY-31%) were more common in RNY (p<0.05). Post-operative leak and morbidity (Clavien-Dindo≥III) were comparable between the two groups.
Follow-up was available for 76% (mean 43.8 months). Good symptom control (61%RF, 65% RNY), good or excellent satisfaction (86% RF, 80% RNY), and recommendation to friend (84% RF, 77% RNY) were similar between groups (p-NS).
Seventy-two (18 RF, 54 RNY) had the high-risk score (≥3) (Table 1). Among these patients, both groups had similar peri-operative outcomes. At follow-up, the percentage of patients reporting severe symptoms were significantly less common with RNY than RF (39% vs 86%, p<0.05). Good or excellent satisfaction (RF-79%, RNY- 74%) and recommendation to friend (RF-71%, RNY-70%) were similar between two groups.
Conclusion
Alternate surgical procedures are increasingly utilized in patients with identifiable risk factors. Perioperative and long-term outcomes are comparable for RF and RNY, however, RNY gives better symptom control in patients with 3 or more risk factors. A preoperative risk stratification may help in decision making for the surgical procedure.

Table 1: Patients with risk score ≥3
RF (n=18) RNY (n=54)
Age (years) Mean�SD 61.3�12.8 56.3�13.4
Sex (Female) 78% 67%
BMI (Kg/m²) Mean�SD 30.3�5.7 34.8�6.6
Risk Score Mean�SD 3.33�0.49 3.44�0.63
Symptom Severity Score (%)
0
1
2
3 0%
46%
46%
8% 2%
62%
37%
0%
Need for PPI 62% 93%
Op Time (min) Mean�SD 219�78 247�66
Blood Loss (cc) Mean�SD 539�715 287�210
ICU stay (days) Mean�SD 3.1�6.5 1.5�4.2
Hospital stay (days) Mean�SD 12.8�13.9 8.2�7.1
Both Vagi not identified/ not saved 16.7% 37%
Splenic injury 11.1% 0%
Hollow viscera perforation 27.8%* 40.7%
Post-operative leak 5.6% 3.7%
Morbidity Clavien Dindo grade ≥III 16.7% 11.1%
Follow-up available 77.8% 85.2%
Follow-up (months) Mean�SD 43.0�26.4 45.7�27.5
Severe symptom (Symptom Score ≥2) 85.7% 39.1%
Good or excellent Satisfaction (score ≥5) 79% 74%
Satisfaction score Mean�SD 7.1�2.7 6.3�2.9
Would recommend 71.4% 69.6%

Figures in bold have p<0.05 between two group.
Tests used: Fisher exact test, Mann-Whitney U test

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