Abstracts
1997 Digestive Disease Week

Reoperative antireflux surgery: procedure selection and outcome.

M Gadenstatter, D Nehra, RJ Mason, JM Collard, MP Ritter, JA Hagen, JH Peters, TR DeMeester. Department of Surgery, University of Southern California, Los Angeles, CA.

Outcome of reoperative antireflux surgery is dependent on the number of previous repairs, the presenting symptoms and on the assessment of functional and anatomic reasons for failure. The aim of this study was 1) to verify the value of anatomic and functional assessment 2) to establish guidelines for procedure selection and 3) to assess the outcome of remedial surgery.

One hundred fourteen patients with failed previous antireflux procedures (median 1, range 1-4) who underwent remedial surgery were reviewed. Functional assessment included barium esophagogram, stationary motility and 24 hour esophageal pH monitoring. Patients with more than 20% simultaneous contractions and/or contraction amplitudes < 25mmHg in the distal esophagus were considered to have ineffective esophageal motility. Anatomic assessment was based on upper endoscopy and intraoperative findings. The reoperative procedure performed was a Nissen fundoplication in 53 patients (normal esophageal length and motility), a Belsey Mark IV procedure in 24 (ineffective esophageal motility) and a Collis gastroplasty and Belsey fundoplication in 19 (short esophagus and ineffective motility). In 18 patients the esophagus was considered to be unsalvageable and was replaced. Outcome was evaluated in 109 patients (96%) at a median of 44 months (range 4-209) via a detailed questionnaire. The primary symptom driving reoperation was dysphagia in 44, heartburn in 38 and a combination of both symptoms in 28 patients. Four patients presented with chest pain alone. Functional assessment and outcome according to the presenting symptoms are shown in the table.

          LES resting    LES      Prevalence of   Esophageal  Excellent/
           pressure    relaxation  ineffective      pH<4        good
            (mmHg)       (%)        motility      (% time)     outcome
Heartburn  6.99±1.02*   88.4±3.1*     18%        12.63±1.36*     92%
Hb + Dys   10.12±1.47*  85.9±3.7*     54%**      16.81±3.25*     78%
Dysphagia  15.04±1.53   54.3±6.0      52%**       1.56±0.42      64%**
*ANOVA; Duncan (significant vs Dys) Mean ± SEM **Fisher's exact test (p<0.01 vs Hb)

Anatomic assessment showed that the repair was misplaced in 44 patients, partially or completely disrupted in 27, herniated into the chest in 18 and too long or too tight in 11. In 14 patients no abnormality was identified. There was no postoperative or hospital mortality. Patients with normal esophageal body motility had a significantly better outcome compared to those with ineffective motility (p<0.05).

Careful assessment prior to remedial antireflux surgery identifies anatomic and functional reasons for failure. The outcome is dependent on the predominant symptom and is least satisfactory in patients with dysphagia. Procedure selection based on functional and anatomic abnormalities optimizes the chance of success.