LAPAROSCOPIC REFUNDOPLICATION: SURGICAL INTERVENTION AFTER FAILED ANTIREFLUX OPERATIONS

(1)

LAPAROSCOPIC REFUNDOPLICATION: SURGICAL INTERVENTION AFTER FAILED ANTIREFLUX OPERATIONS

R. Pointner

Department of General Surgery, Public Hospital of Zell am See, Zell am See, Austria

Chapter 20

Introduction

The progress of laparoscopic surgery and a more profound understanding of the pathophysiological conditions leading to gastroesophageal reflux disease have resulted in a revival of antireflux surgery. Since 1991 [1] the laparoscopic Nissen and Toupet fundoplication and their modifications have emerged as the surgical alternative for treatment of GERD. The reduced morbidity and an approximately cero per cent mortality rate in combination with excellent outcomes following laparoscopic approaches have encouraged surgeons to a more liberal indication to surgery and have also raised patient’s expectations for a perfect outcome. Success and failure rates depend on a precise indication to surgery and on the frequency how often the procedure is performed in the institution and by a single surgeon [2]. As the

“learning curve” for laparoscopic antireflux procedures even in centers is low, redo procedures require surgeons experienced in GERD and in laparoscopy, too. With the increase in laparoscopic antireflux procedures the debate has ceased whether redo fun- doplications should be done open or laparoscop- ically. There is no doubt, that the standard for redo procedures after failed antireflux surgery is the mini- mal invasive technique for both, primary open and primary laparoscopic surgery, even if there are usu- ally more adheasions and technical difficulties following a previous open procedure.

Diagnosis

Antireflux surgery is failed, if the patient is not able to swallow undisturbed, reports about epigastric pain or shows the same symptoms of reflux disease which were the initially reasons for primary antireflux sur-

gery. In addition to persisting or new onset symptoms the quality of life in these patients is typically lower than before primary surgery [3]. The analysis of the underlying failures which are responsible for the reported symptoms is essential for a successful treatment. Possible failures and adverse outcomes following laparoscopic antireflux surgery are discussed in the chapter before. Reviewing the literature, 5 to 20 per cent of all patients who underwent antireflux procedures have to be treated again because of new onset or persistent reflux symptoms [4]. These symptoms are either dysphagia, recurring or persistent reflux or a combination of both, reflux and dysphagia. Aim of the diagnostic procedure is to clarify the morphologic changes that are responsible for the above mentioned symptoms. Patients description of the kind, intensity and beginning of new or recurrent symptoms after primary antireflux procedures are essential comments for a further analysis. In combination with a distinct anamnesis, the evaluation has to clarify whether the wrap is open or too loose, whether the hiatus or the wrap is too tight and to define the position of the wrap with regard to the diaphragm or the fundus. The most important tool is a barium X-ray swallow using a videographic or kinematographic technique. For both, a skilled radiologist and an experienced antireflux surgeon, it should be possible to define the position of the former constructed wrap in relation to the diaphragm and the crura.To confirm or exclude a radiologically suspected diagnosis upper GI endoscopy is empha- sized in every patient. Beneeth the visualisation and histologic documentation of obvious leasons or stric- tures, the location of the gastroesophageal junction must be defined above or below the diaphragmatic crura. Further more, the typical “Nissen nipple” can be seen in the so called inversion of the scope and cleary-

(2)

212 Chapter 20

advocated. The reintervention should be done within the first week. At the beginning of the second postoperative week reoperation becomes more diffi- cult and should therefore be done only after three months again. At reintervention the wrap and the hiatus have to be inspected to make clear, what the cause for dysphagia is. In every case the fundoplication has to be taken down for having a good look at the hiatus. If the hiatus was too tight, the uppermost suture has to be removed, followed by recreating a loose Nissen or Toupet fundoplication. A fifty french bougie can be passed carefully into the stomach to clarify whether the hiatus is wide enough or another suture has to be opened.

As just mentioned reintervention should be avoid- ed between the second week and third month after surgery and patients should be treated conservatively in this period if ever possible.

Late reoperation

Late postoperative problems are recurrent gastroesophageal reflux, dysphagia or a combination of both. In case of recurrent reflux, patients can be ma- naged conservatively in most cases. Only if quality of life is lower than before the primay surgical procedure, reintervention is indicated. A reason for recurrent reflux is either a too loose wrap or the suspected brake down of the primary intact original fundoplication. As mentioned in the chapters before, recurrent reflux occurs more often following a Toupet than a Nissen procedure. Fortunately the fundoplication in these patients can easily be reconstructed. At first, all adheasions from the stomach to the surrounding liver, diagphragm or fat have to be dis- sected. The preparation has to be done in a way, that the fundus becomes as mobile as it should have been at primary surgery. Whether a Nissen or Toupet fundoplication is reconstructed does not depend on the former constructed wrap, but should be a result of the body motility at the moment of redo surgery.

Beneeth recurrent reﬂux redo surgery is indicated in patients with the symptom of persistent dysphagia over months in combination with a decreased quality of life. These cases are rare, since dysphagia solely related to the wrap or the diaphragm has either to be operated on in the early stage or becomes better and ﬁes whether the plication is in the right position or

not. To exclude functional problems it makes sense to examine the body motility as well as the emptying of the stomach.

Early reintervention

Only in rare cases, reintervention is indicated in an early stage after primary surgery. Fortunately severe life threatening problems following laparoscopic fundoplication are quite rare. They are caused by in- jury of the gastric wall, esophagus, or parts of the in- testinal tract, leading to perforation or peritonitis. In these cases, when suspicion arouses that a perforation could have taken place, earliest reintervention is advocated. If an esophageal leak is the reason for early reintervention, this leak has to be identified exactly. For a definite identification an endoscope or tube in the esophagus can help to find the leak. In case of a small damage of the esophageal wall the leak can be oversewn with a few stiches but should be covered by a part of the fundoplication. If the leakage is bigger or more than a quarter of the cir- cumference conversion to open and distal esophageal resection is advocated. There is no doubt, that the procedure has to begin with breaking down the sutures of the fundoplication for a better visualisation of the complete area. Perforations following laparoscopy of the intestine are handled as perforations following open surgery.

Speciﬁcally fundoplication related early complications are uncommon. Beneeth the life threatening problems of perforations, acute dysphagia is the most troublesome early complication. The reason for early dysphagia may be an acute postoperative re-hiatal herniation with a slipping wrap which possibly can lead to incarceration intrathoracically. It should be mentionend, that in the early postoperative stage less force is required to push the stomach into the thorax, since the normal anatomical barriers have been disrupted by surgical dissection. If the wrap has been constructed too tight or the hiatus was closed too tight, dysphagia occurs within the ﬁrst two days resulting in complete inability to swallow even sa- liva. In this case a swallow X-ray with a soluble contrast should be performed. If no contrast passes from the esophagus into the stomach early reoperation is

(3)

Pointner R 213

disappears within one year in the majority of patients.

Therefore a very cautious proceeding is advocated and if nutrition is adequately maintained, waiting for al- most a year before considering surgical revision should be encouraged. Redo surgery should then be performed more easily. Whilst it is difﬁcult to be certain what the underlying cause of dysphagia is, a reexplora- tion before surgical intervention should be done. The investigation of joice is a diagnostic pneumatic dilata- tion in general anesthesia. The ﬁgure of the dilated balloon on X-ray control shows, whether the stenosis is related to the wrap or the diaphragm. A hiatal related stenosis shows the typical radiological pricture of a sand-glas form. Laparoscopic reintervention con- tains not only the dissection of all adheasions with the break down of the wrap but the complete exposition of the hiatus with the preparation of the distal and intrathoracically positioned part of the esophagus too.

Then the crural sutures have to be opened until a ﬁfty french bougie slides unhindered into the stomach. If the stenosis is related to excessive parahiatal scar tissue this has to be removed, followed by the reconstruction of a normal wide hiatus. If the underlying problem of persistant dysphagia is a primary too tight wrap the fundoplication has to be devided and unravelled fully.

A new and loose wrap has to be constructed and it is appropriate to perform a posterior 270 or 180

Toupet fundoplication even if an esophageal manome- try demonstrates normal esophageal body peristalsis.

In cases when the actual cause of dysphagia is not clear, widening of the hiatus and conversion to a Toupet fundoplication should both be performed.

The most frequent symptom leading to late redo surgery is the combination of reﬂux and dysphagia.

This combined problem can occur as a result of a rehiatal hernia with the consecutive migration of a part or the total wrap intrathoracically, the so called “Slip- ping Nissen”. These patients experience dysphagia as a result of a beginning strangulation of the wrap or the upper part of the stomach in between the crural branches with gastric mucosa above the stenosis resulting in peptic reﬂux. The symptoms in patients with a herniation of a part of the fundus through an intact wrap, the so called “telescoping” are the same, recurrent reﬂux and dysphagia. A telescope phenome- non can occur with or without a rehiatal hernia.

Indication for redo surgery in these patients is a decreased quality of life compared to the quality of

life score before primary surgery. The operative strategy is always the same: deviding the adheasions from the stomach to the liver, the diaphragm and the fat, unravelling the previous fundoplication and exposing the diaphragmatic crura and the esophageal hiatus. It is essential to lengthen the esophagus by extensive preparation of its distal intrathoracically part. Only if the complete unravelled fundus and the distal esophagus lay loose without tension intraab- dominally the reconstruction of the new hiatus and refundoplication can start.

Although for every patient undergoing redo surgery, the kind of the fundoplication can be predicted preoperatively the correction of the hiatus can only be established intraoperatively. The strategy there is according to the individual patient and his particular hiatal problem. It has to be decided whether the crura should be adapted only with sutures or armed by a small or circular prosthetic material. In contrast to this kind of closure of the hiatus with tension on the crura the hiatus can be closed in a tension free technique using a special mesh. As mentioned in a chapter before, there is no doubt, that the use of prosthetic material in repairing a large hiatal hernia reduces the risk of recurrent herniation.

Results

According to the literature, mortality for laparoscop- ically done refundoplications is not higher than for primary procedures. It can be estimated that the complication rates are even lower since redo procedures generally are done more in centers with surgeons more skilled in antireﬂux surgery and in laparoscopy.

Open reoperation after open failed antireﬂux surgery is associated with a mortality of about 2 per cent and a morbidity of 20 to 40 per cent [4], [5]. Even in centers excellent to good results can only be expectet in 85 per cent of patients after open redo surgery. In the literature, there are only a few articles available deal- ing with a greater number of patients having undergone redo fundoplication [6]. The reported mortility in these papers is zero as it is in our serie of more than 150 redo procedures too. Morbidity and reported complications are unessential higher than in case of primary laparoscopic fundoplication. Data from the literature emphasize that patients assess the result

(4)

214 Chapter 20

able, avoidable, or a waste of time? Ann Surg 224:

198–203

[3] Kamolz T, Granderath PA, Bammer T, Pasiut M, Wykypiel H Jr, Herrmann R, Pointner R (2002) Mid- and long-term quality of life assessments after laparoscopic fundoplication and refundoplication: a single unit review of more than 500 antireﬂux procedures. Dig Liver Dis 34: 470–476

[4] Stein HJ, Feussner H, Siewert JR (1996) Failures of antireﬂux surgery: causes and management strategies.

Am J Surg 171: 36–40

[5] Little AG, Ferguson MH, Skinner DB (1986) Reop- erations for failed antireﬂux operations. J Thorac Cardiovasc Surg 91: 511–519

[6] Pohl D, Eubanks TR, Omelanczuk PE, Pellegrini CA (2001) Management and outcome of complications after laparoscopic antireﬂux operations. Arch Surg 136:

399–404

[7] Granderath FA, Kamolz T, Schweiger UM, Pointner R (2002) Long-term follow-up after laparoscopic refundoplication for failed antireﬂux surgery: quality of life, symptomatic outcome and patient satisfaction. J Gas- trointest Surg 6: 812–818

[8] Eypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schmülling C, Neugebauer E, Troidl H (1995) Gastroin- testinal quality of life index: development, validation and application of a new instrument. Br J Surg 82:

216–222 of redo surgery as excellent to good in 65 to 85 per

cent [7]. In case of a poor result (in 10 to 20 per cent), with persisting or new onsert symptoms a second or even third reintervention can be done without more problems than at the ﬁrst refundoplication. Even in these patients in our series the success rates are as high as they are after the ﬁrst reintervention. The quality of life in redo patients evaluated by means of the gastrointestinal quality of life index [8]

is not much worse compared to those after success- fully done primary surgery but much more better than before primary laparoscopic fundoplication.

Laparoscopic revisional surgery in patients having undergone open fundoplication is feasible too with the restriction that adheasions from the stomach to the liver, to diaphragm and to the adominal wall are much more pronounced compared to patients with previous laparoscopic surgery.

References

[1] Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R (1991) Laparoscopic Nissen fundoplication:

preliminary report. Surg Laparosc Endosc 1: 138–143 [2] Watson DI, Baigrie RJ, Jamieson GG (1996) A learn-

ing curve for laparoscopic fundoplication. Defin-