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CONVERSION TO FUNDOPLICATION VS. FUNDOPEXY IN THE MANAGEMENT OF REOPERATIVE LAPAROSCOPIC ANTIREFLUX SURGERY
Karsten Fields
2, Neel Aligave
*2, Connor Fritz
2, Clarissa Hoffman
2, Shalin Shah
2, Raymar Turangan
2, Sylvestre Pineau
2, Megan Mai
3, Farzaneh Banki
11Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Southeast Esophageal Disease Center, Houston, TX; 2The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 3The University of Texas Health Science Center at Houston, Houston, TX
Aim: To assess the outcomes of reoperative laparoscopic antireflux surgery and optimal management.
Methods: Retrospective study, single center/single surgical team. Kaplan-Meier methods and log-rank testing were used to compare symptomatic recurrence requiring reoperation in patients with fundoplication conversion to fundoplication vs. fundoplication conversion to fundopexy.
Results: From 04/28/2011 to 09/19/2024, there were 1128 hiatal hernia repairs with 95/1128 (17.3%) reoperative procedures in 177 patients, 108/177 (61.0%) had their initial operation at another center, 17/177 (9.6%) required a second reoperative procedure at our center, and 1/177 (0.6%) required a third, 180/195 (92.3%) were laparoscopic and 15/195 (7.7%) transabdominal [9/15 (60%) Roux-en-y, last performed on 02/25/2019]. Fundoplication conversion to fundoplication was performed in 94/195 (48.2%), fundoplication conversion to fundopexy in 78/195 (40.0%), fundoplication conversion to Roux-en-y in 9/195 (4.6%), and others in 14/195 (7.2%). Indications included recurrent hiatal hernia in 161/195 (82.6%), tight fundoplication in 12/195 (6.2%), and others in 22/195 (11.2%). Comparing conversion to fundoplication in 94/195 (48.2%) to conversion to fundopexy in 78/195 (40.0%) showed no difference in age/sex/BMI/ASA. Type I hiatal hernia was seen in 23/94 (24.5%) vs. 3/78 (3.8), p<0.001, and type III in 45/94 (47.9%) vs. 50/78 (64.1%), p=0.048. Duration of operation was 173.0 min (147.0- 211.2) vs. 151.0 (130.0 -177.0), p=0.002, LOS was 2.0 days (1.0-4.0) vs. 0.0 (0.0 -2.0), p<0.001 and same-day surgeries were 3/94 (3.2%) vs. 40/78 (51.3%), p<0.001. There were no leaks and no 30-day mortality. At a median follow-up of 103.4 months (71.7-125.2) vs. 33.0 months (17.8-41.3), p<0.001, symptomatic recurrence requiring reoperation occurred in 13/94 (13.8%) vs. 0/78 (0.0%), p<0.001. The time to reoperation for 13 patients was 23.5 months (16.6-40.1). Patients with conversion to fundoplication had more symptomatic recurrences than those with conversion to fundopexy by log-rank test (p=0.0134). At the 3-year follow-up, symptomatic recurrence in conversion to fundoplication was 8.41%, and in conversion to fundopexy 0%. At 3-year follow-up, 10/13 (76.9%) recurrences occurred in the conversion to the fundoplication group.
Conclusions: Reoperative laparoscopic antireflux surgery can be performed with minimal morbidity and as same-day surgery in select patients. Despite differences in median follow-up time, symptomatic recurrence requiring reoperation is lower in the conversion to fundopexy than in conversion to fundoplication. Longer follow-up and randomized studies are required to confirm the advantages of fundopexy.
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