Surgical fundoplication
360° Fundoplication (Nissen Fundoplication)
180° Posterior fundoplication (Toupet Fundoplication)
180° Anterior fundoplication (Dor Fundoplication)
Posterior gastropexy (Hill Procedure)
Transthoracic posterior plication (Belsey Procedure)
Endoluminal procedures
Radiofrequency application to LES (Stretta)
Transoral Incisionless Fundoplication (TIF)
When considering why an antireflux operation has failed, broadly speaking, there are three reasons that an operation will fail to control a patient’s symptoms and/or GERD.
1.
Errors in work-up or patient selection
2.
Errors in operative management
3.
Natural history of the particular antireflux operation or condition being treated
If no. 1 and 2 above can be standardized, and the natural history of the operation and condition being managed is understood, then predictable outcomes should result. For example, from large series from high volume surgeons and centers, we know that in the setting of clinically and objectively confirmed GERD, with symptoms that are PPI responsive, normal esophageal motility, a body mass index less than 35, and no other confounding conditions, one would expect a 90 % likelihood that 10 years after surgery a patient will have continued control of their GERD, both objectively and symptomatically [1].
Regardless of which of the three reasons outlined above underlies the need for reoperation, defining and understanding the pattern of failure will guide subsequent management. One typically sees failure of a fundoplication in a few distinct patterns. These are outlined in Table 22.2 and Figs. 22.1 and 22.2. When considering these reasons for failure, hiatal hernia is the most common cause (44 % of cases). Wrap disruption or breakdown is the next leading cause accounting for 16 % of failures. Slipped wraps account for 11.7 % of failure, and finally, wraps improperly positioned at the time of their initial construction are found in 3.9 % of cases. Wrap or crural stenosis is a rare cause of failure and often times hard to determine as a primary etiology of failure.
Table 22.2
Patterns of failure
Wrap disruption or loosening |
Wrap migration or slip |
Hiatal herniation or re-herniation |
Wrap or crural stenosis |
Wrap too loose or misplaced at the initial operation |
Fig. 22.1
Common anatomic patterns of antireflux surgery failure: (a) fundoplication disruption, (b) tight fundoplication or crural stenosis, (c) slipped fundoplication, (d) hiatal herniation
Fig. 22.2
Illustration of incorrectly created fundoplication compared to correct creation
If mesh was used at the initial operation, a distinctly different pattern of failure and management strategy is needed. This is discussed later in this chapter.
Presentation and Work-up
Early Versus Late Failure
Failure of an antireflux operation can occur immediately or many years later. Characterizing the failure as early or late is the beginning point in determining the possible reason for failure and will help guide a thoughtful investigation and subsequent management.
Early Failure
Most commonly, early failure is the result of early postoperative nausea and vomiting, or some other trauma causing an abrupt rise in intra-abdominal pressure. The abrupt increase in intra-abdominal pressure that accompanies something like violent retching or a fall striking one’s abdomen is thought to either tear stitches or tissue resulting in immediate wrap disruption or slip, or alternatively, breakdown of the cruroplasty and immediate herniation or the wrap or abdominal content above the diaphragm.
If a patient experiences such an event within a few days of surgery it is recommended to immediately obtain a contrast swallow, and if an anatomic abnormality is found to immediately return the patient to the operating room. Within the first few days from surgery it is usually an easy matter to re-wrap a disrupted or migrated wrap, or pull a herniated wrap back into the abdomen and redo a cruroplasty. Not uncommonly, if the crura have become disrupted, especially if a hiatal hernia repair accompanied the first procedure, a more advanced technique such as a remote diaphragm release to effect crural mobilization and mesh repair of the diaphragmatic defect may be needed (Figs. 22.3 and 22.4). If acute disruption occurs more than a few days after the operation, it is best to wait 6–12 weeks before attempting to correct the anatomic problem. If one attempts to intervene sooner than this you are more likely to encounter dense adhesions and an extremely difficult dissection with accompanying risk of injury to the stomach, esophagus, or vagus nerve(s). Also, if attempting a redo in this early timeframe it is best to have considerable experience with reoperative antireflux surgery since these can be some of the most difficult redos to complete safely and attain good results.
Fig. 22.3
Intraoperative photo depicting primary closure of esophageal hiatus with relaxing incision in diaphragm for hiatal reconstruction of large hiatal defect
Fig. 22.4
Intraoperative photo depicting primary closure of esophageal hiatus with mesh patch of diaphragm relaxing incision
Another more rare cause of immediate failure is a technical error during surgery such as a misplaced wrap, a tight cruroplasty, or a tight wrap. Technical failure at the time of surgery is typically not appreciated until months later when a pattern of unremitting pain, nausea, vomiting, or dysphagia that started immediately postoperatively is further investigated and an anatomic abnormality found. These reasons for failure are unlikely to be identified by the surgeon who performed the first operation, but rather, when a patient or the original surgeon seeks a second opinion. As a subsequent surgeon getting involved in a patient’s care, while technical error as the reason for failure might be suspected, it is crucial to not opine as to this possibility since it cannot be known for certain, and patients may wrongfully attribute failure to an error and pursue litigation. Only an undisputable and egregious error at the time of the first surgery would warrant such a path.
Finally, initial misdiagnosis or poor patient/procedure selection can lead to early failure. Unfortunately, there are still patients undergoing antireflux surgery without objective confirmation of GERD, misinterpretation of esophageal motility studies leading to wraps when achalasia is the diagnosis, and aggressive management of the esophageal hiatus in the absence of significant hiatal hernia, i.e., routine use of mesh hiatoplasty. In all cases of early failure, regardless of cause, if the problem is not found within a few days of the first operation, it is best to wait at least 3 months or longer before undertaking a redo.
Late Failure
More commonly, antireflux operations fail late with late failure defined as a patient who has had an initial good result with more than 90 days of resolution, or near resolution of symptoms, and no new foregut symptoms, who then develops recurrent or new symptoms. This definition is meant to isolate late failures from those that are immediate but have a later presentation. The majority of late failures are due either to wrap disruption, hiatal hernia, or to esophageal outlet issues from a restricted esophageal outlet (scarring, twisting, or crural stenosis).
Symptoms of Failure
Common symptoms of failure of an antireflux operation are outlined in Table 22.3. Of these, recurrent GERD is the most common (59 %), and dysphagia (31 %) the next most common. While these symptoms can occur with any or all of the patterns of failure, there are patterns of symptoms that correlate highly with a given mechanism of failure (Fig. 22.5). Gross anatomic abnormalities such as hiatal hernia or severe wrap/crural stenosis are more likely to present with symptoms related to poor esophageal transit and emptying. These symptoms commonly include dysphagia, chest pain, and regurgitation. The wrap that has loosened or come undone more commonly presents with recurrent GERD symptoms, often identical to those being experienced before the first antireflux procedure. Commonly this includes typical symptoms such as heartburn, regurgitation, and chest pain, but can also be more atypical symptoms like cough, laryngitis, or asthma. Again, the relationship and similarity of symptoms to those before the initial operation is strongly predictive of wrap disruption or loosening. Finally, the patient with a slipped wrap will often have a broad constellation of symptoms with more prevalence of nausea and epigastric pain than the other presentations. Overall, a favorable response to antisecretories and postural regurgitation can provide additional clues as to the possibility of wrap loosening or incompetence, while poor tolerance of foods of a more heavy consistency and weight loss can often predict hiatal herniation or esophageal outlet issues. Improvement with dilation also supports esophageal outlet restriction. Failure of symptoms to respond to any intervention including antisecretory medication or dilation is more likely with wrap slippage.
Table 22.3
Common symptoms of antireflux surgery failure
Heartburn |
Chest pain |
Regurgitation |
Dysphagia |
Nausea |
Bloating |
Shortness of Breath (SOB) |
Aspiration |
Fig. 22.5
Symptoms of antireflux surgery failure correlated with anatomic pattern of failure
A confounding variable in presenting symptoms is the patient who will present with early postprandial bloating or meal induced diarrhea. In these cases one should be suspicious of dysfunctional gastric emptying as a result of vagal nerve injury or inflammation. Delayed gastric emptying and/or dumping can be a hallmark of vagal nerve injury and often is associated with antireflux surgery. This symptom complex in the absence of an obvious anatomic abnormality or a positive pH test should lead one to pursue further work-up rather than a redo antireflux operation. More surgery at the esophageal hiatus or gastroesophageal junction is unlikely to improve gastric function and may worsen the situation with potential vagal nerve injury and re-injury.
Work-up
When considering testing for suspected antireflux surgery failure, it helps to think about the investigations aimed at securing a diagnosis or reason for failure versus testing needed for planning a redo operation. An algorithm for the work-up of patients suspected to have failed a prior antireflux operation is shown in Fig. 22.6.
Fig. 22.6
Flow chart of work-up for possible antireflux surgery failure
Establishing the Diagnosis
In pursuit of a diagnosis of failure, the work-up should start with an anatomic assessment. This usually includes an upper endoscopy (EGD) and contrast esophagram. Often, a contrast esophagram is all that is needed to identify the pattern of failure. Figure 22.7 depicts the esophagram findings corresponding to the various patterns of failure. Alternatively, an EGD may clearly show an anatomic abnormality, but since an upper endoscopy is often performed by a gastroenterologist who may not be familiar with the endoscopic findings of failure, we often find an esophagram the most helpful for the surgeon to interpret, or an endoscopy performed by a surgeon experienced in reoperative foregut surgery and upper endoscopy. If relying on endoscopy performed by someone other than the foregut surgeon it is helpful to have photos from the endoscopy available, especially retroflex views where abnormal findings are often most readily seen. The common endoscopic findings of failure are outlined in Table 22.4.
Fig. 22.7
Contrast swallow examples for each common anatomic pattern of failure
Table 22.4
Endoscopic findings of failed antireflux operation
Viewing location | Findings (pattern of failure) |
|---|---|
Retroflex view of distal esophagus | Gastric folds extending into wrap (slipped/misplaced fundoplication) |
Esophagogastric junction does not hug scope (loose or undone fundoplication) | |
Gastric mucosa extending above hiatal indentation (hiatal hernia) | |
Forward view of distal esophagus | Narrowing that doesn’t accept scope (tight wrap or crural stenosis) |
Esophagitis/esophageal ulcers (loose or undone fundoplication) | |
Constriction on proximal stomach below constriction of wrap (hiatal hernia) | |
Constriction of wrap distal to esophagogastric junction (slipped or misplaced wrap) |
In many cases, if the presenting symptoms correlate with findings on an esophagram or EGD this is all that is needed to diagnosis failure and the need for reoperation. If these tests fail to identify an obvious anatomic cause for a patient’s symptoms then further testing is required. If recurrent GERD is the dominant presentation then pH testing should be obtained. When pursuing pH testing it is critical to obtain this test with the patient off of all antisecretory medication. Increasingly, pH tests are being obtained while on medication, especially with the increased use of impedance pH testing. While this approach may reveal non-acid reflux, one should be very cautious about relying entirely on this test to decide about offering a reoperation. It is my strong recommendation that a pH off medication be obtained. If this confirms pathologic acid reflux the complexity of offering a redo based on the primary diagnosis of non-acid reflux can be avoided.
Planning for Operative Management
With a diagnosis of antireflux surgery failure secured, and a correctable pattern of failure identified, further testing may be indicated to help plan the most effective reoperative strategy. During a redo one must not only correct the primary anatomic problem, but also take steps to prevent another failure. This may include modifying the type of fundoplication or adjunct procedures to mitigate future complications that could lead to failure. The most common conditions associated with failure that need to be investigated are esophageal motility problems and impairment in gastric emptying. With this in mind, all patients should undergo an esophageal motility study and a gastric emptying study before being returned to an operating room for redo surgery.
Impairment in esophageal motility may indicate the need for a partial, 270° fundoplication, rather than a 360° fundoplication. Classically a partial fundoplication should be considered if normal esophageal peristalsis is present in less than 70 % of swallows, or esophageal body contraction pressure is less than 30 mmHg. A newer technique, high-resolution manometry (HRM), is providing a more detailed analysis of esophageal motor and propulsive function. The additional data collected with HRM often results in a diagnosis of “ineffective esophageal motility” (IEM) based on the Chicago classification of esophageal motility. This new label of IEM is poorly understood in the context of reoperative antireflux surgery. Until the clinical relevance of the IEM label is better understood, using the body pressure and percent peristalsis for decision-making about full or partial fundoplication is recommended.
Delayed gastric emptying may require the addition of a gastrostomy tube to provide gastric decompression in the early postoperative period thereby preventing gastric distension induced crural or wrap disruption, or performance of a concomitant pyloroplasty. Pyloroplasty is indicated for patients whose gastric ½ emptying time is greater than twice normal. Those with less severe delayed gastric emptying may respond to anatomic correction alone and thereby avoid the risk of long-term diarrhea that can occur after pyloroplasty.
A possible exception to obtaining an esophageal motility study is the patient with a large recurrent hiatal hernia. It can be very difficult to obtain a motility study in these patients due to the distorted esophageal anatomy, and interpreting the results can be difficult.
Operative Management
Reoperative antireflux surgery can be some of the more challenging foregut operations undertaken by a surgeon. Understanding the likely cause of failure aids in preoperative planning and approach, and intraoperative strategy. For example, if the cause of failure is hiatal hernia, especially recurrent hiatal hernia, one should be prepared to undertake an extensive mediastinal dissection of the esophagus to achieve adequate intra-abdominal esophageal length, even being prepared to perform a Collis gastroplasty for esophageal lengthening. When dealing with multiple prior failures, positioning for an open approach and possible thoracoabdominal incision is prudent. Alternatively, managing late failure for a wrap that has loosened would be unlikely to require extensive dissection or include direct thoracic access.
Operative Approach
For a skilled laparoscopic surgeon, almost all redos can be approached laparoscopically. Prior foregut surgery rarely results in adhesions or scarring making laparoscopic abdominal access impossible, and the magnification and facilitated exposure afforded by laparoscopy in the upper abdomen make a laparoscopic approach to these difficult cases preferred. I will in nearly all circumstances start laparoscopically. Early conversion to an open approach is more likely in the following situations:
Multiple prior foregut procedures, especially prior open repairs
Hiatal hernia with a significant amount of the stomach incarcerated in chest, especially if mesh was used in prior operations
Prior operations that were complicated by postoperative leak, fistula, or early reoperation.
In these situations where one may predict a higher likelihood of conversion, it is prudent to be prepared for not only an open approach, but also even a thoracoabdominal approach. Rather than position the patient for possible thoracoabdominal approach and compromise the initial laparoscopic approach (thoracoabdominal approach requires positioning the patient in semi-lateral decubitus position) I prefer to re-prep and drape if conversion to an open thoracoabdominal approach is needed.
In general, a split leg approach is used in nearly all foregut surgery (Fig. 22.8). If possible conversion to an open approach is anticipated, one arm should be tucked so that a table mounted retraction system can be secured at the patient’s shoulder well away from the surgeons’ standing position at the patient’s side for open access.
