PRIMARY SYMPTOM INDICATION CAN BE A PREDICTOR FOR OUTCOMES IN REVISIONAL ANTI REFLUX SURGERY
Sailakshmi Krishnan*
New South Wales Ministry of Health, St Leonards, New South Wales, Australia
Background:
Revisional hiatus hernia surgery may be indicated in select cases of recurrence after primary surgery. Furthermore, a small percentage of these patients require more than one revisional surgery . Several studies have been performed on this subject, but they have a small data set and have paucity of information on pre-operative and intra operative findings .
Methods:
A prospectively maintained single-surgeon database from 1992 to 2022 of revisional hiatus hernia surgery was retrospectively evaluated. The results of the pre-operative assessments were collated to identify the symptomatic, anatomical and physiological indications for surgery. Intra-operative outcomes, including the type and size of failure and the subsequent repair performed, were obtained by reviewing the operation reports. Post-operative outcomes assessed included degree of symptom resolution, as well as quality of life measures through validated scoring systems such as the GIQLI 3, Visick 4, Watson dysphagia 5, and Reflux Symptom Index 6 scores.
Results:
The dataset consisted of 381 patients, of whom 59% were female. The average age of this cohort at the time of primary revisional surgery was 59 years (range 19-91). A single revisional operation was carried out in 340 cases, while 35 cases underwent two revision surgeries and 6 cases underwent more than two revision surgeries. The most common indication for primary surgery in patients who had one revision surgery was classical reflux symptoms (44%), followed by volume symptoms (33%), obstructive symptoms (10%) and non-specific abdominal symptoms such as early satiety, bloating, pain (10%). However, patients who had a second revision surgery more likely to have initially presented with volume symptoms (37%) and patients who had more than two revision surgeries were most likely to have presented with non-specific abdominal symptoms such as early satiety, bloating, pain (63%). The most common intra-operative finding in revision surgery was crural failure and wrap herniation (52%) and crural failure and wrap disruption (14.6%). In patients where the indication for revisional surgery was obstructive symptoms, no defect was found in 25% compared to the mean of 8%.
An overall improvement was seen in measured outcomes following revisional surgery, with similar rates of improvement in patients who had multiple revisional surgeries. The mean dysphagia score increased from 28 to 33, the mean reflux symptom index decreased from 23.2 to 16 and the mean Visick score decreased from 3.2 to 2.5.
Conclusions:
Patients who initially presented with volume symptoms and non-specifical abdominal symptoms were more likely to have multiple revisional surgeries than patients who presented classical reflux symptoms.
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