40

Revisional antireflux surgery

PETER G. DEVITT, ARAVIND SUPPIAH AND SARAH K. THOMPSON

INTRODUCTION

Antireflux surgery is a well-established treatment for gastroesophageal reflux disease, with long-term success rates in the region of 80%-90%. Perhaps some 1% of individuals with troublesome symptoms undergo surgery and of these, a further 1%-5% will have recurrent or persistent symptoms that lead to some form of revisional surgery.

Symptomatic problems after antireflux surgery can be associated with a poor quality of life, making revisional surgery an attractive proposition for some. Although not as effective as primary repair, revisional antireflux surgery is associated with good outcomes, with patient satisfaction rates of 70%-85%. Revisional antireflux surgery may remain the only meaningful therapeutic measure for symptom relief for some patients—provided they are carefully selected and thoroughly evaluated.

The potential benefit must be balanced against the known risks. These include the operative risks of an increased conversion rate (1.5%-10.0%), increased operating time (up to 180 minutes), and a recognized complication rate in terms of bleeding and gastric and/or esophageal perforation (5%-10%). Patients also need to be aware of the higher rate of persistence or recurrence of symptoms compared with a first-time antireflux procedure. These rates can be as high as 15%-30%. While difficult to quantify, patients’ expectations of any planned revisional surgery must be considered.

A laparoscopic approach is the standard of care for most patients contemplating primary antireflux surgery. Similarly, laparoscopic intervention is the first choice for revisional surgery—even for those patients whose initial operation was done through an open approach. Adhesion formation is variable and a previous laparotomy does not necessarily preclude a laparoscopic approach for revisional surgery—although these patients should be warned about the increased risk of conversion. The obvious advantages of laparoscopic revision include decreased pain scores, fewer wound complications, reduced postoperative morbidity, shorter hospital stay, and more rapid resumption of normal duties.

PREOPERATIVE ASSESSMENT AND PREPARATION

Symptom evaluation

A careful symptom assessment must be made in any patient contemplating revisional antireflux surgery. The most common symptom is recurrent reflux, occurring in 50%-70% of patients seeking revisional surgery. Some 30%-50% of patients will have dysphagia, with an overlap of 10%-30% having both reflux and dysphagia.

With regards to reflux symptoms, clarification must be sought in terms of:

• Details of presenting symptoms and their relief by the initial operation
  
• imilarity of current symptoms to those that led up to the initial procedure
  
• Possible reasons for return of symptoms
  
• Expectations of the patient

Persistence or recurrence or new symptoms after antireflux surgery does not necessarily equate with a failure of the initial procedure and may reflect an initial misinterpretation by both patient and surgeon as to the origin of the symptoms. Supporting this is the observation that most patients who take a proton pump inhibitor after antireflux surgery do not have objective evidence of reflux.

Patients presenting with recurrent reflux have better outcomes than those presenting with dysphagia with no anatomical or manometric abnormality. Patients who had primary surgery for atypical symptoms (e.g., voice change or cough) are unlikely to have a satisfactory outcome from revisional antireflux surgery, particularly if the initial operation did not provide any symptomatic relief.

Patients with new symptoms typically complain of dysphagia or gas bloat. Both of these symptoms are common after fundoplication and are usually transient. The patients should have been warned about their occurrence prior to initial surgery and these problems are best dealt with by reassurance and managing patient expectations. However, any persistence or worsening of symptoms may require investigation. Obviously, complete dysphagia will demand early laparoscopic reoperation.

The possible reasons for recurrence of symptoms must be considered and they include:

• The hiatus:
  
  
  
  • Too tight (dysphagia)
    
  • Too loose (recurrence of hernia and/or reflux)

• The wrap:
  
  
  
  • Too tight (dysphagia)
    
  • Slipped in position (reflux and/or dysphagia)
    
  • Intact fundoplication migrated into chest (reflux and/ or dysphagia)
    
  • Undone (reflux)

• Other:
  
  
  
  • Vagal damage with gastric stasis (bloating)
    
  • Poor esophageal motility (dysphagia)
    
  • Inappropriate initial operation (persistence of original symptoms)

Perhaps the last reason is the most important to consider if the current symptoms are persistence or rapid reappearance of symptoms after the initial operation. In other words, although the patient might have had objective evidence of gastro-esophageal reflux, this might not have been the cause of the symptoms or the patient might have had unrealistic expectations of what surgery would achieve.

Objective assessment

Persisting or recurrent reflux symptoms require further investigation and this includes 24-hour pH studies, esophageal manometry, endoscopy, and contrast evaluation. All patients require this full work-up. Many patients with recurrent reflux symptoms will be found to have normal pH studies. Patients with pathologic acid exposure on postoperative pH studies and/or positive symptom correlation are more likely to benefit from revisional antireflux surgery than those with normal studies. Patients with persistent dysphagia are associated with poor postrevisional surgery outcomes.

Some patients who do not demonstrate pathologic overall acid exposure time (due to the wrap) but have good symptom correlation (symptom index and symptom association probability) and/or endoscopic esophagitis may be reasonable candidates for revisional antireflux surgery. Predictors for poor outcome in revisional antireflux surgery performed for reflux symptoms are persistent (not recurrent) symptoms after primary surgery and normal pH exposure with poor symptom correlation.

Endoscopy

Ideally, the upper gastrointestinal endoscopy should be performed by the operating surgeon. This is done to assess wrap position and presence of any hiatal hernia (better seen on a contrast study). Evidence of reflux should be sought in terms of esophageal mucosal erosion. Other causes for the symptoms might be identified, such as gastritis (acidor bileinduced) or peptic ulcer, which would then dictate alternate therapies. Refer to Chapter 27, “Endoscopy,” for further information on endoscopic assessment of prior antireflux surgery.

Contrast study

A contrast study may be performed to determine any anatomical anomaly in terms of:

1. Intact wrap migration. This can be defined as partial (Type I) defect in which the wrap has partially migrated into the chest, with the gastro-esophageal junction remaining below the diaphragm (see Figure 40.1) or
   
2. a total (Type II) migration where the entire gastroesophageal wrap complex has migrated up into the chest (see Figure 40.2).
   
3. Wrap slippage (intact wrap which has slipped in position down onto the stomach leading to “gastric band effect” or “bilobed” stomach).
   
4. Primary wrap unwrapping.

Stay updated, free articles. Join our Telegram channel

Join