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FEASIBILITY AND TECHNIQUE OF CONVERSION TO REFLUXSTOP FROM PREVIOUS ANTIREFLUX SURGERY IN GERD PATIENTS: EXPERIENCE WITH 24 PATIENTS
Thorsten G. Lehmann
*1, Joerg Zehetner
21General- and Visceral Surgery, Klinikum Friedrichshafen GmbH, Friedrichshafen, Baden-Württemberg, Germany; 2Hirslanden Klinik Beau-Site, Bern, Switzerland
BackgroundAntireflux surgery (ARS) techniques can have postoperative manifestations such as recurrent reflux, dysphagia, migration/explant (surgical devices), reherniation (hiatal hernia), and erosion that may prompt redo surgery. These procedures may preclude later treatment due to their technical characteristics and physiologic implications, presenting difficulty in next step decision-making should treatment failure occur. We report the feasibility and surgical technique of conversion to RefluxStop surgery from previously failed ARS.
MethodsA retrospective analysis of patients from two centers was conducted to assess the feasibility of RefluxStop surgery for GERD patients with failure of previous ARS. Eligible patients had either previous Nissen fundoplication, Toupet fundoplication, MSA, EndoStim, or BICORN. Feasibility and surgical technique are descriptively discussed.
ResultsIn total, 24 patients underwent conversion to RefluxStop surgery from previous MSA (38%), Toupet fundoplication (29%), Nissen fundoplication (13%), Dor fundoplication (8%), BICORN (8%), and EndoStim (4%) surgery. Overall, it is feasible to perform RefluxStop surgery on patients experiencing failure of previous ARS. Fundoplication failure typically consists of loosening and hiatal hernia recurrence. Conversion involves attentive dissection of plication from all esophageal/hiatus attachments with careful unwrapping (vagal nerves) followed by hiatus repair. In the uncommon event of severely diminished fundic musculature, we refrain from RefluxStop implantation. If MSA does not function adequately, the device can be removed by cutting the device encapsulation from 8-4 o’clock. Hernia repair is performed, if needed, and RefluxStop surgery is performed as recommended, mobilizing untouched fundus prior to left-sided partial fundoplication. Fundoplication sometimes involves potential challenges posed by fibrosis of fundus tissue, neither of which is applicable with conversion from MSA which easier to perform. All patients discontinued regular PPI use at follow-up. One RefluxStop device penetrated through the stomach and passed naturally through the digestive tract without any further intervention; likely from a ‘worn out’ fundus with almost nonexistent musculature.
ConclusionThis study summarizes the technical feasibility and safety of conversion of previously failed ARS to the RefluxStop procedure in the surgical treatment of persistent GERD in 24 patients. Conversion is feasible with all techniques and conversion from MSA or EndoStim particularly facile.
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