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Laparoscopic Revision of Failed Antireflux Operations
Journal of Surgical Research 95, 13–18 (2001) doi:10.1006/jsre.2000.6015, available online at http://www.idealibrary.com on
Laparoscopic Revision of Failed Antireflux Operations F. M. Serafini, M. Bloomston, E. Zervos, J. Muench, M. H. Albrink, M. Murr, and A. S. Rosemurgy Department of Surgery, University of South Florida, Tampa, Florida 33601 Presented at the 24th Annual Symposium of the Association of Veterans Administration Surgeons Meeting, Seattle, Washington, April 9 –11, 2000; published online November 8, 2000
INTRODUCTION Background. A small number of patients fail fundoplication and require reoperation. Laparoscopic techniques have been applied to reoperative fundoplications. We reviewed our experience with reoperative laparoscopic fundoplication. Methods. Reoperative laparoscopic fundoplication was undertaken in 28 patients, 19 F and 9 M, of mean age 56 years ⴞ 12. Previous antireflux procedures included 19 open and 12 laparoscopic antireflux operations. Results. Symptoms were heartburn (90%), dysphagia (35%), and atypical symptoms (30%%). The mean interval from antireflux procedure to revision was 13 months ⴞ 4.2. The mean DeMeester score was 78 ⴞ 32 (normal 14.7). Eighteen patients (64%) had hiatal breakdown, 17 (60%) had wrap failure, 2 (7%) had slipped Nissen, 3 (11%) had paraesophageal hernias, and 1 (3%) had an excessively tight wrap. Twenty-five revisions were completed laparoscopically, while 3 patients required conversion to the open technique. Complications occurred in 9 of 17 (53%) patients failing previous open fundoplications and in 4 of 12 patients (33%) failing previous laparoscopic fundoplications and included 15 gastrotomies and 1 esophagotomy, all repaired laparoscopically, 3 postoperative gastric leaks, and 4 pneumothoraces requiring tube thoracostomy. No deaths occurred. Median length of stay was 5 days (range 2–90 days). At a mean follow-up of 20 months ⴞ 17, 2 patients (7%) have failed revision of their fundoplications, with the rest of the patients being essentially asymptomatic (93%). Conclusions. The results achieved with reoperative laparoscopic fundoplication are similar to those of primary laparoscopic fundoplications. Laparoscopic reoperations, particularly of primary open fundoplication, can be technically challenging and fraught with complications. © 2001 Academic Press Key Words: antireflux surgery; laparoscopic fundoplication; reoperative laparoscopic fundoplication; 24-h ambulatory pH study; esophageal manometry.
The introduction of minimally invasive technology to the treatment of functional disorders of the esophagus, such as gastroesophageal reflux disease, has increased the number of laparoscopic antireflux fundoplications undertaken. Increased acceptance by patients and referring physicians of “minimally invasive” operations and increased awareness of the complications of GERD help to explain the increased number of laparoscopic antireflux procedures undertaken [1]. The success of antireflux procedures, including laparoscopic operations, has been documented in large series with considerable follow-up [2– 4]. Although rates of failure are quite variable, failure of open or laparoscopic fundoplications is usually reported around 10%, ranging between 3 and 30% [5–7]. This variability is in part dependent upon definitions of failure, which may vary from center to center, differing in operative techniques and patient selection. It is evident, however, that when surgeons progress along the learning curve of laparoscopic fundoplications the number of laparoscopic antireflux procedures that will require revision decreases noticeably [8, 9]. Hunter et al. reported that only 3.4% of 1000 patients underwent revision after laparoscopic fundoplication, with most of the failures occurring at the beginning of their experience [10]. Before the advent of laparoscopic antireflux surgery, all fundoplications, including revisions of failed antireflux operations, were undertaken with “open” techniques. Early in the experience with laparoscopic antireflux operations, surgeons were reluctant to use laparoscopic techniques to treat failed fundoplications because of anticipated technical difficulties. However, with progression along the learning curve of minimally invasive surgery and laparoscopic antireflux surgery, laparoscopic skills developed to a degree that anticipated technical difficulties were no longer perceived to be insurmountable [10 –15]. Increased awareness of
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0022-4804/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
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JOURNAL OF SURGICAL RESEARCH: VOL. 95, NO. 1, JANUARY 2001
the pathophysiology of GERD and growing numbers of laparoscopic fundoplications have lead to small but increasing numbers of failed laparoscopic fundoplications, which have increasingly been approached with laparoscopic techniques. The first aim of this study was to review the outcomes of laparoscopic revisions of failed antireflux operations undertaken at our institution. The second aim of this study was to review the technical difficulties of laparoscopic revisions of failed open antireflux procedures relative to failed laparoscopic procedures. We thought that laparoscopic revisions of failed fundoplications impart significant morbidity while generally leading to results comparable to those of primary antireflux operations. Furthermore, we thought that laparoscopic revision of failed open antireflux procedures is technically more challenging and more prone to complications leading to longer hospital stays when compared to laparoscopic revision of failed laparoscopic fundoplications. METHODS From March 1994 to February 2000, 28 patients (19 females and 9 males) of mean age of 56 years ⫾ 12 (STD) underwent laparoscopic reoperations for failed antireflux procedures. Patients were initially evaluated because of excessive dysphagia or recurrence of symptoms due to significant gastroesophageal reflux. Twenty-three (82%) patients had undergone primary antireflux surgery at outside institutions and 5 (18%) patients at our medical center. Seventeen (60%) patients had undergone open antireflux operations, 10 (36%) had undergone laparoscopic antireflux procedures, and 1 (4%) had undergone both laparoscopic and open fundoplications. Primary antireflux procedures included open Nissen fundoplications in 14 (50%) patients and laparoscopic Nissen fundoplication in 9 (32%). Additionally, 1 patient underwent two laparoscopic Nissen fundoplications and 1 (3%) patient underwent two open Nissen fundoplications. One (3%) patient underwent a laparoscopic Nissen fundoplication first, subsequently revised by an open Nissen fundoplication. One (3%) patient had placement on an Angelchick ring via celiotomy, and 1 (3%) patient had an open Toupet fundoplication. Patients were first evaluated for failure of their initial antireflux operation because of recurrence of symptoms. Twenty-five (90%) patients had heartburn, 10 (35%) patients had dysphagia, 10 (35%) had regurgitation, 9 (32%) had abdominal pain, 6 (21%) had significant and notable cough, 5 (18%) patients had abdominal bloating, and 4 (14%) patients had persistent diarrhea requiring medical treatment. The most commonly utilized “antireflux” medications were H2-blockers in 20 (71%) patients, proton pump inhibitors in 11 (39%) patients, and promotility agents in 8 (28%) patients. Two patients (7%) were receiving theophylline and steroids due to asthma caused by continuous acid reflux. Laparoscopic revision of failed antireflux procedures was considered in patients with significant recurrent symptoms refractory to medications and with objective evidence of failure of their initial antireflux operation by abnormal UGI barium contrast study and/or abnormal 24-h ambulatory pH study. Failure of the original antireflux procedure was confirmed with upper gastrointestinal barium study in 28 (100%) patients and by 24-h ambulatory pH-monitoring study in 21 (75%) patients. Stationary esophageal manometry was undertaken in 17 (60%) patients. Endoscopy was undertaken in 15 (53%) patients. The DeMeester score obtained through the ambulatory pH study before laparoscopic reoperation averaged 78 ⫾ 32
(normal ⬍14.7). Preoperative mean LES pressure was 8 mm Hg ⫾ 4 (normal 15–30 mmHg). The mean interval from most previous (three patients had undergone two fundoplications) antireflux procedure to laparoscopic reoperative fundoplication was 13 months ⫾ 4.2 (STD). Patterns of failure of the antireflux operations were defined in the operating room as follows: ● wrap failure: the wrap had come partially or completely undone, but the stomach was still in the abdomen; ● hiatus failure: herniation of an intact wrap into the chest through the esophageal hiatus; ● combined wrap and hiatal failure: the presence of a wrap which was partially or completely undone and herniation of the stomach into the chest; ● paraesophageal herniation: persistence of the wrap below the diaphragm, but a variable part of the stomach herniated through a diaphragmatic defect into the chest; ● slipped Nissen: presence of the wrap in the peritoneal cavity, but the gastroesophageal junction was above or cephalad to the wrap in the chest.
Patient follow-up was undertaken through clinic appointments and telephone calls scheduled at regular intervals. Data are presented as means ⫾ STD when appropriate.
DESCRIPTION OF THE LAPAROSCOPIC REOPERATION
All revisional laparoscopic fundoplications began by cut-down placement of an Hussan cannula at the umbilicus. All other trocars were placed under videoscopic guidance. A fan retractor was placed through the port along the right anterior axillary line cephalad to the umbelicus and was used to retract the left lobe of the liver away from the gastroesophageal junction. Three additional ports were placed: one subxyphoid and always below the liver edge for the camera and two operating ports along the midclavicular lines as they crossed the subcostal margins. The sequence of port placement was determined by the pattern of adhesions, which were divided with the harmonic scalpel to expose the anterior surface of the stomach. The dissection of the hiatus was undertaken with great care to safely identify both left and right crura. The identification of the left crus was easiest and safest by approaching it from along the greater curve of the stomach and taking down the short gastric vessels, which may have not been divided at the previous operation. Division of the short gastric vessels leads to a relatively clear plane behind the stomach, facilitating the dissection of the left crus, the posterior side of the esophagus, and eventually the right crus. After the hiatus and the esophagus were identified, the esophagus was mobilized up into the mediastinum to reestablish 6 to 8 cm of intraabdominal esophagus. Last, the attention was given to the wrap, or what was left of the primary wrap, and the wrap was completely mobilized and dissected from adhesions to evaluate its status. After defining the anatomy of the hiatus, esophagus, and stomach, including the wrap, we were able to define the cause of failure of the previous fundoplication
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SERAFINI ET AL.: LAPAROSCOPIC REOPERATIVE FUNDOPLICATION
TABLE 1 Type of Failure of Primary Fundoplication Findings
Laparoscopic
Open
Isolated wrap failure Isolated hiatus failure Combined wrap and hiatus failure Slipped Nissen with hiatus failure Wrap too tight
5 2 3 0 1
2 6 7 2 0
and, therefore, start the reconstruction of the fundoplication. The esophageal hiatus was adequately closed about the esophagus to allow for a food bolus to pass. Then the attention was given to the reconstruction of the fundoplication. In the presence of an undone wrap, a new one is fashioned over a 54- to 60-F bougie dilator. If the wrap was found to be partially undone, then the old wrap was repaired, if indicated, and reconstructed over a 54- to 60-F bougie. The decision to construct a total wrap (360°) or a partial wrap (270°) was based upon esophageal function and esophageal clearance mechanisms determined by the preoperative UGI contrast study and/or stationary manometry. For either total or posterior fundoplications, the posterior fundus of the wrap was sewn to the diaphragmatic crura very caudad to secure the fundoplication in the abdomen and to limit tension, which might encourage the wrap to come undone. At completion of the operation, all port sites were closed with a nonabsorbable monofilament suture and skin was approximated with absorbable suture and steri-strips. RESULTS
Twenty-eight patients underwent reoperation to revise failed antireflux procedures. Reconstruction of the fundoplication was completed laparoscopically in 26 patients (93%), whereas 2 patients (7%) required conversion to open procedures because of dense adhesions. Both of these patients had undergone and failed open antireflux Nissen fundoplications. Wrap failure was found in 2 (7%) patients failing open fundoplication and in 5 (18%) patients after laparoscopic fundoplications. Breakdown of the hiatal reconstruction led to revision in 6 (21%) patients after open fundoplications and 2 (7%) after laparoscopic fundoplications. Seven (25%) more patients failing open operations and 3 (10%) patients failing laparoscopic antireflux operations presented with failure of both the hiatal reconstruction and fundoplication wrap. Slipped Nissen was present in 2 (7%) patients failing open fundoplications, and wrap stricture after laparoscopic fundoplication led to revision in 1 (3%) patient (Table 1). Of the 5 patients failing fundoplications undertaken
at our institution, 4 had been undertaken laparoscopically and 1 with the open technique. Of the 4 failed laparoscopic fundoplications, wrap failure was responsible for failure in 1 patient, isolated hiatus failure in 2 patients, and combined hiatus and wrap failure in the 4th patient. The patient failing open fundoplication demonstrated failure of hiatus and unwinding of the wrap. According to the technique described previously, 23 patients (82%) underwent Nissen fundoplication (22 operations were completed laparoscopically and 1 required conversion to an open procedure). Five patients (18%) underwent partial fundoplications because of esophageal dysmotility. Four of these procedures were completed laparoscopically and 1 required conversion to an open technique (3 laparoscopic posterior fundoplication, 1 laparoscopic anterior fundoplication, and 1 laparoscopic posterior fundoplication converted to an open procedure). One patient underwent concomitant percutaneous tracheostomy due to poor pulmonary function, and 1 patient underwent concomitant cholecystectomy because of known symptomatic cholelithiasis. Inadvertent intraoperative events occurred in 13 patients (46%), in 9 patients during laparoscopic revision of failed open antireflux operations and in 4 patients during laparoscopic reoperation for failed primary laparoscopic fundoplications. The intraoperative events included isolated pneumothoraces in 2 patients, isolated gastrotomies in 5 patients, multiple enterotomies (more than one gastrotomy or gastrotomy associated with esophagotomy) in 5 patients, and splenic injury in 1 patient requiring four RBC transfusions. Four of the 5 (80%) patients who suffered inadvertent multiple enterotomies also had pleural injuries (Table 2). The median intraoperative blood loss was 50 ml (20 – 1000 ml). The median intraoperative blood loss for patients who underwent laparoscopic revisions of an open fundoplications was 62 ml (range 20 – 400 ml) and 50 ml (range 20 –1000 ml) for patients undergoing laparoscopic revisions of laparoscopic fundoplications. The mean length of the operation was 203 min ⫾ 66. The mean operative time to complete laparoscopic reoperative fundoplication was 216 min ⫾ 67 for patients after previous open antireflux procedures and 184 TABLE 2 Unanticipated Events Occurring in Thirteen Patients during Laparoscopic Revisions of Failed Antireflux Procedures Complication
Laparoscopic
Open
Gastrotomy Esophagotomy Pneumothorax Bleeding
3 0 2 1
7 1 4 0
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min ⫾ 64 for patients failing primary laparoscopic fundoplications. Postoperative complications occurred in six patients (21%). These included esophageal or gastric leaks in three (10%) patients (two after laparoscopic revision of open antireflux operations and one after revision of primary laparoscopic fundoplication), intrabdominal hematoma requiring surgical evacuation in one (3%) patient, myocardial infarction in one patient (3%), and cerebrovascular accident in one patient (3%). The esophagogastric leaks were managed nonoperatively in one patient and with surgical drainage and decortication in the other two patients (thoracoscopy in one patient, thoracotomy in one patient). No fatalities occurred in our series. The median hospital stay was 5 days (range 2–90). The median hospital stay in patients undergoing laparoscopic revision of failed open antireflux surgeries was 5 days (1–90 days), compared to 2.5 days (2–28 days) for patients undergoing laparoscopic revisions of failed laparoscopic fundoplications. The median hospital stay for patients who sustained intraoperative inadvertent events during reoperative laparoscopic fundoplication was 7 days (3–90 days) compared to 2 days (1– 60 days) for patients with uneventful laparoscopic revisions. At a mean follow-up of 20 months ⫾ 14, 25 patients (89%) are free from symptoms of gastroesophageal reflux and are off all preoperative antireflux medications. Three (11%) patients had recurrent heartburn and further workup demonstrated failure of the revised fundoplications. One patient has already undergone revision of her fundoplication revision through an open Toupet fundoplication. The other two patients did not consent to further operations. One additional patient had an esophageal stricture following a leak. This was treated with endoscopic dilation, and she is now able to eat without difficulties. DISCUSSION
The role of laparoscopy in the treatment of failed antireflux procedures is not well established. While several recent reports have documented the utility and efficacy of laparoscopic reoperative antireflux surgery, the risks associated with reoperative laparoscopic fundoplications are not well documented [10 –13]. This study reports the results of reoperative laparoscopic fundoplications undertaken for failed antireflux procedures and focuses on the differences in outcomes and risks of laparoscopic revisions of open antireflux operations and of laparosopic revisions of primary laparoscopic fundoplications. Over 5 years we undertook laparoscopic reoperations in a relatively small number of patients failing antireflux procedures constructed with an open or laparoscopic technique. These patients were generally older females, often with several comorbidities (coronary ar-
tery disease, asthma, COPD). More than two-thirds of the patients were referred from outside facilities, and more than two-thirds of the primary antireflux operations had been constructed with open techniques. A small number of patients had undergone multiple previous antireflux procedures. In general, the previous antireflux operations had been undertaken more than a year earlier. Patients were evaluated because of recurrent symptoms of GERD or dysphagia refractory to antireflux medications, considering them suspicious for failure of their original antireflux operation. Diagnosis of failure of their original fundoplication was undertaken only with abnormal findings on UGI contrast study, 24-h ambulatory pH study, manometry, and/or endoscopy. The UGI contrast study is the first, and most important, piece of information used to define failure of an antireflux operation. Additionally, the UGI contrast study undertaken in a 15° head-down position will provide useful information on anatomy and function of the esophagus, which will ultimately determine the type of fundoplication constructed at reoperation (total versus partial). As well, esophageal manometry can objectively determine the propulsive strength of the esophagus and may give useful information helpful in tailoring the antireflux operation to achieve the best outcome, although the interpretation of subtle manometric abnormalities in esophageal function can be difficult. With symptoms of GERD or dysphagia and normal UGI contrast study consistent with previous antireflux surgery, determination of the De Meester score by 24-h ambulatory pH study is appropriate. The causes of failure of primary antireflux operations were different for open and laparoscopic procedures. Additionally, the location where the primary operation had been undertaken influenced also the mechanism of failure of the antireflux procedure. For example, patients failing laparoscopic antireflux operations originally undertaken at our institution most frequently presented with breakdown of the hiatal reconstruction, whereas patients failing laparoscopic fundoplications constructed at outside facilities most frequently presented with failure of the wrap (completely or partially undone). This last finding is in contrast to most published literature, and it is probably due to inadequate laparoscopic techniques. On the other hand, failure of open antireflux operations was more frequently due to disruption of the hiatal reconstruction, and failure of laparoscopic fundoplications was more frequently associated with unwinding of the wrap. The mechanisms of disruption of the hiatus closure are not entirely understood. However, a wellconstructed wrap with a poorly mobilized esophagus, because of tension, could result in herniation of the fundoplication into the chest. We think that at the time of initial fundoplication it is necessary to mobilize the
SERAFINI ET AL.: LAPAROSCOPIC REOPERATIVE FUNDOPLICATION
esophagus sufficiently to reestablish at least 6 to 8 cm of intraabdominal esophagus and we believe that the laparoscopic approach easily allows this. Obesity and, in general, circumstances associated with increased abdominal pressure may also facilitate esophageal hiatus breakdown. Technical errors, such as poor approximation of the diaphragmatic crura or poor purchases through the muscles, inevitably lead to failure of the hiatal reconstruction. The esophageal hiatus should be closed appropriately snugly on the esophagus and the wrap should be anchored to the diaphragm to minimize the chances for herniation of the wrap into the chest, particularly early after surgery before scarring can develop. Even in the absence of notable hiatal hernia, we always oppose the crura with at least one stitch, assuming that our dissection has disrupted the phrenoesophageal membrane, predisposing it to later hiatal disruption and hernia formation. As previously stated, wrap failure was a common intraoperative finding after laparoscopic fundoplication, particularly after laparoscopic fundoplications undertaken at outside hospitals. Early in the experience with laparoscopic antireflux surgery, division of the short gastric vessels was not perceived essential and was felt to be technically challenging by many surgeons. We believe that division of the short gastric vessels is very important. Inadequate mobilization of the gastric fundus allows tension along the wrap, ultimately promoting unwinding of the fundoplication. Small tissue purchases at the time of the construction of the wrap can constitute another reason for failure of the wrap. Intraoperative inadvertent events, such as gastrotomies, esophagotomies, pneumothoraces, and splenic injuries, occurred more frequently in patients undergoing revision of failed open antireflux operations. This was probably related to increased technical difficulties related to dense adhesions. The increased technical difficulty is also reflected in longer operating times and higher blood loss occurring in patients undergoing revisions of open fundoplications. The conversion rate for reoperative laparoscopic fundoplications is generally reported to be near 10% (0 – 20%) [10 –15]. Eight percent of our patients required intraoperative conversion from laparoscopic to open fundoplication because of the inability of adequately identifying the anatomy due to dense adhesions. Length of hospital stay is generally reported to be around 3 days (2–5 days) [10 –15]. The median hospital stay of our patients was 5 days. However, in our series, hospital stay was prolonged in patients experiencing inadvertent intraoperative enterotomies. As well, hospital stay was found to be longer in patients undergoing laparoscopic revision of failed open antireflux operations compared to those patients undergoing laparoscopic revision of primary laparoscopic proce-
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dures, primarily due to an increased occurrence of intraoperative gastrotomies. These results demonstrate that laparoscopic reoperation for failed antireflux surgery, although challenging, can be undertaken with minimally invasive techniques. Accurate selection of the patients for such operation will provide the best outcomes. Patients presenting after fundoplication with mild symptoms of reflux or occasional dysphagia should not be considered for reoperation if their symptoms are well controlled by adjunctive medications. On the other hand, those patients presenting with severe symptoms of reflux or dysphagia after fundoplication and demonstrating abnormal results at UGI contrast study or 24-h ambulatory pH study should be considered candidates for laparoscopic reoperative antireflux surgery. We believe that laparoscopic revision of open fundoplications was substantially more challenging and more prone to complications than laparoscopic revisions of laparoscopic fundoplications. Although “difficulty” cannot be quantified directly, measures of difficulty, such as length of the operation and intraoperative blood loss, were significantly higher in patients requiring revision of open fundoplications. Redo laparoscopic fundoplications should be undertaken following the same steps of primary laparoscopic fundoplications, with careful definition of the anatomy, adequate mobilization of the esophagus, and construction of an adequate wrap. From our experience with laparoscopic revision of failed antireflux procedures, we have learned many lessons. The first and foremost lesson learned is that antireflux procedures need to be undertaken with great care and attention to operative details the first time. Such care and attention will help to minimize the number of failures and need for reoperations. Laparoscopic reoperative antireflux surgeries can be technically easier and less prone to complications when undertaken in patients failing primary laparoscopic fundoplications as opposed to primary open fundoplications. However, because of the difficulty of laparoscopic reoperations and the possibility of serious complications causing potentially prolonged hospital stays, the diagnosis of failure of antireflux operations and the indications for laparoscopic reoperative fundoplication must be defined upon abnormal UGI contrast study or 24-h ambulatory pH study. Ultimately, the need for reoperative laparoscopic antireflux surgery must always be carefully weighed against procedure-related and patient-specific risks (e.g., cardiac diseases, pulmonary diseases). REFERENCES 1. 2.
Synergy Healthcare, Inc., Waltham, MA, 1999. Hinder, R. A., Filipi, C. J., Wetscher, G., Neary, P., DeMeester, T. B., and Perdikis, G. Laparoscopic Nissen fundoplication is an
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JOURNAL OF SURGICAL RESEARCH: VOL. 95, NO. 1, JANUARY 2001 effective treatment for gastroesophageal reflux disease. Ann. Surg. 220: 472, 1994. Landrenau, R. J., Wiechmann, R. J., Hazelrigg, S. R., Santucci, T. S., Boley, T. M., Magee, M. J., and Naunheim, K. S. Success of laparoscopic fundoplication for gastroesophageal reflux disease. Ann. Thorac. Surg. 66: 1886, 1998. DeMeester, T. R., Bonavina, L., and Albertucci, M. Nissen fundoplication for gastroesophageal reflux disease. Ann. Surg. 204: 9, 1986. Skinner, D. B., Klementschtisch, P., Little, A. G., DeMeester, T. R., and Belsey, R. R. H. assessment of failed antireflux repairs. In T. R. DeMeester, and D. B. Skinner (Eds.), Esophagal Disorders: Pathophysiology and Threapy. New York: Raven Press, 1986. Pp. 303–313. Dallamagne, B., Weerts, J. M., Jehaes, C., and Markiewicz, S. Causes of failures of laparoscopic antireflux operations. Surg. Endosc. 10: 305, 1996. Soper, N. J., and Dunnegan, D. Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann. Surg. 229: 669, 1999. Watson, D. I., Baigrie, R. J., and Jamieson, G. G. A learning curve for laparoscopic fundoplication: Definable, avoidable, or a waste of time? Ann. Surg. 24: 198, 1996.
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Laparoscopic Revision of Failed Antireflux Operations F. M. Serafini, M. Bloomston, E. Zervos, J. Muench, M. H. Albrink, M. Murr, and A. S. Rosemurgy Department of Surgery, University of South Florida, Tampa, Florida 33601 Presented at the 24th Annual Symposium of the Association of Veterans Administration Surgeons Meeting, Seattle, Washington, April 9 –11, 2000; published online November 8, 2000
INTRODUCTION Background. A small number of patients fail fundoplication and require reoperation. Laparoscopic techniques have been applied to reoperative fundoplications. We reviewed our experience with reoperative laparoscopic fundoplication. Methods. Reoperative laparoscopic fundoplication was undertaken in 28 patients, 19 F and 9 M, of mean age 56 years ⴞ 12. Previous antireflux procedures included 19 open and 12 laparoscopic antireflux operations. Results. Symptoms were heartburn (90%), dysphagia (35%), and atypical symptoms (30%%). The mean interval from antireflux procedure to revision was 13 months ⴞ 4.2. The mean DeMeester score was 78 ⴞ 32 (normal 14.7). Eighteen patients (64%) had hiatal breakdown, 17 (60%) had wrap failure, 2 (7%) had slipped Nissen, 3 (11%) had paraesophageal hernias, and 1 (3%) had an excessively tight wrap. Twenty-five revisions were completed laparoscopically, while 3 patients required conversion to the open technique. Complications occurred in 9 of 17 (53%) patients failing previous open fundoplications and in 4 of 12 patients (33%) failing previous laparoscopic fundoplications and included 15 gastrotomies and 1 esophagotomy, all repaired laparoscopically, 3 postoperative gastric leaks, and 4 pneumothoraces requiring tube thoracostomy. No deaths occurred. Median length of stay was 5 days (range 2–90 days). At a mean follow-up of 20 months ⴞ 17, 2 patients (7%) have failed revision of their fundoplications, with the rest of the patients being essentially asymptomatic (93%). Conclusions. The results achieved with reoperative laparoscopic fundoplication are similar to those of primary laparoscopic fundoplications. Laparoscopic reoperations, particularly of primary open fundoplication, can be technically challenging and fraught with complications. © 2001 Academic Press Key Words: antireflux surgery; laparoscopic fundoplication; reoperative laparoscopic fundoplication; 24-h ambulatory pH study; esophageal manometry.
The introduction of minimally invasive technology to the treatment of functional disorders of the esophagus, such as gastroesophageal reflux disease, has increased the number of laparoscopic antireflux fundoplications undertaken. Increased acceptance by patients and referring physicians of “minimally invasive” operations and increased awareness of the complications of GERD help to explain the increased number of laparoscopic antireflux procedures undertaken [1]. The success of antireflux procedures, including laparoscopic operations, has been documented in large series with considerable follow-up [2– 4]. Although rates of failure are quite variable, failure of open or laparoscopic fundoplications is usually reported around 10%, ranging between 3 and 30% [5–7]. This variability is in part dependent upon definitions of failure, which may vary from center to center, differing in operative techniques and patient selection. It is evident, however, that when surgeons progress along the learning curve of laparoscopic fundoplications the number of laparoscopic antireflux procedures that will require revision decreases noticeably [8, 9]. Hunter et al. reported that only 3.4% of 1000 patients underwent revision after laparoscopic fundoplication, with most of the failures occurring at the beginning of their experience [10]. Before the advent of laparoscopic antireflux surgery, all fundoplications, including revisions of failed antireflux operations, were undertaken with “open” techniques. Early in the experience with laparoscopic antireflux operations, surgeons were reluctant to use laparoscopic techniques to treat failed fundoplications because of anticipated technical difficulties. However, with progression along the learning curve of minimally invasive surgery and laparoscopic antireflux surgery, laparoscopic skills developed to a degree that anticipated technical difficulties were no longer perceived to be insurmountable [10 –15]. Increased awareness of
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0022-4804/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
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the pathophysiology of GERD and growing numbers of laparoscopic fundoplications have lead to small but increasing numbers of failed laparoscopic fundoplications, which have increasingly been approached with laparoscopic techniques. The first aim of this study was to review the outcomes of laparoscopic revisions of failed antireflux operations undertaken at our institution. The second aim of this study was to review the technical difficulties of laparoscopic revisions of failed open antireflux procedures relative to failed laparoscopic procedures. We thought that laparoscopic revisions of failed fundoplications impart significant morbidity while generally leading to results comparable to those of primary antireflux operations. Furthermore, we thought that laparoscopic revision of failed open antireflux procedures is technically more challenging and more prone to complications leading to longer hospital stays when compared to laparoscopic revision of failed laparoscopic fundoplications. METHODS From March 1994 to February 2000, 28 patients (19 females and 9 males) of mean age of 56 years ⫾ 12 (STD) underwent laparoscopic reoperations for failed antireflux procedures. Patients were initially evaluated because of excessive dysphagia or recurrence of symptoms due to significant gastroesophageal reflux. Twenty-three (82%) patients had undergone primary antireflux surgery at outside institutions and 5 (18%) patients at our medical center. Seventeen (60%) patients had undergone open antireflux operations, 10 (36%) had undergone laparoscopic antireflux procedures, and 1 (4%) had undergone both laparoscopic and open fundoplications. Primary antireflux procedures included open Nissen fundoplications in 14 (50%) patients and laparoscopic Nissen fundoplication in 9 (32%). Additionally, 1 patient underwent two laparoscopic Nissen fundoplications and 1 (3%) patient underwent two open Nissen fundoplications. One (3%) patient underwent a laparoscopic Nissen fundoplication first, subsequently revised by an open Nissen fundoplication. One (3%) patient had placement on an Angelchick ring via celiotomy, and 1 (3%) patient had an open Toupet fundoplication. Patients were first evaluated for failure of their initial antireflux operation because of recurrence of symptoms. Twenty-five (90%) patients had heartburn, 10 (35%) patients had dysphagia, 10 (35%) had regurgitation, 9 (32%) had abdominal pain, 6 (21%) had significant and notable cough, 5 (18%) patients had abdominal bloating, and 4 (14%) patients had persistent diarrhea requiring medical treatment. The most commonly utilized “antireflux” medications were H2-blockers in 20 (71%) patients, proton pump inhibitors in 11 (39%) patients, and promotility agents in 8 (28%) patients. Two patients (7%) were receiving theophylline and steroids due to asthma caused by continuous acid reflux. Laparoscopic revision of failed antireflux procedures was considered in patients with significant recurrent symptoms refractory to medications and with objective evidence of failure of their initial antireflux operation by abnormal UGI barium contrast study and/or abnormal 24-h ambulatory pH study. Failure of the original antireflux procedure was confirmed with upper gastrointestinal barium study in 28 (100%) patients and by 24-h ambulatory pH-monitoring study in 21 (75%) patients. Stationary esophageal manometry was undertaken in 17 (60%) patients. Endoscopy was undertaken in 15 (53%) patients. The DeMeester score obtained through the ambulatory pH study before laparoscopic reoperation averaged 78 ⫾ 32
(normal ⬍14.7). Preoperative mean LES pressure was 8 mm Hg ⫾ 4 (normal 15–30 mmHg). The mean interval from most previous (three patients had undergone two fundoplications) antireflux procedure to laparoscopic reoperative fundoplication was 13 months ⫾ 4.2 (STD). Patterns of failure of the antireflux operations were defined in the operating room as follows: ● wrap failure: the wrap had come partially or completely undone, but the stomach was still in the abdomen; ● hiatus failure: herniation of an intact wrap into the chest through the esophageal hiatus; ● combined wrap and hiatal failure: the presence of a wrap which was partially or completely undone and herniation of the stomach into the chest; ● paraesophageal herniation: persistence of the wrap below the diaphragm, but a variable part of the stomach herniated through a diaphragmatic defect into the chest; ● slipped Nissen: presence of the wrap in the peritoneal cavity, but the gastroesophageal junction was above or cephalad to the wrap in the chest.
Patient follow-up was undertaken through clinic appointments and telephone calls scheduled at regular intervals. Data are presented as means ⫾ STD when appropriate.
DESCRIPTION OF THE LAPAROSCOPIC REOPERATION
All revisional laparoscopic fundoplications began by cut-down placement of an Hussan cannula at the umbilicus. All other trocars were placed under videoscopic guidance. A fan retractor was placed through the port along the right anterior axillary line cephalad to the umbelicus and was used to retract the left lobe of the liver away from the gastroesophageal junction. Three additional ports were placed: one subxyphoid and always below the liver edge for the camera and two operating ports along the midclavicular lines as they crossed the subcostal margins. The sequence of port placement was determined by the pattern of adhesions, which were divided with the harmonic scalpel to expose the anterior surface of the stomach. The dissection of the hiatus was undertaken with great care to safely identify both left and right crura. The identification of the left crus was easiest and safest by approaching it from along the greater curve of the stomach and taking down the short gastric vessels, which may have not been divided at the previous operation. Division of the short gastric vessels leads to a relatively clear plane behind the stomach, facilitating the dissection of the left crus, the posterior side of the esophagus, and eventually the right crus. After the hiatus and the esophagus were identified, the esophagus was mobilized up into the mediastinum to reestablish 6 to 8 cm of intraabdominal esophagus. Last, the attention was given to the wrap, or what was left of the primary wrap, and the wrap was completely mobilized and dissected from adhesions to evaluate its status. After defining the anatomy of the hiatus, esophagus, and stomach, including the wrap, we were able to define the cause of failure of the previous fundoplication
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SERAFINI ET AL.: LAPAROSCOPIC REOPERATIVE FUNDOPLICATION
TABLE 1 Type of Failure of Primary Fundoplication Findings
Laparoscopic
Open
Isolated wrap failure Isolated hiatus failure Combined wrap and hiatus failure Slipped Nissen with hiatus failure Wrap too tight
5 2 3 0 1
2 6 7 2 0
and, therefore, start the reconstruction of the fundoplication. The esophageal hiatus was adequately closed about the esophagus to allow for a food bolus to pass. Then the attention was given to the reconstruction of the fundoplication. In the presence of an undone wrap, a new one is fashioned over a 54- to 60-F bougie dilator. If the wrap was found to be partially undone, then the old wrap was repaired, if indicated, and reconstructed over a 54- to 60-F bougie. The decision to construct a total wrap (360°) or a partial wrap (270°) was based upon esophageal function and esophageal clearance mechanisms determined by the preoperative UGI contrast study and/or stationary manometry. For either total or posterior fundoplications, the posterior fundus of the wrap was sewn to the diaphragmatic crura very caudad to secure the fundoplication in the abdomen and to limit tension, which might encourage the wrap to come undone. At completion of the operation, all port sites were closed with a nonabsorbable monofilament suture and skin was approximated with absorbable suture and steri-strips. RESULTS
Twenty-eight patients underwent reoperation to revise failed antireflux procedures. Reconstruction of the fundoplication was completed laparoscopically in 26 patients (93%), whereas 2 patients (7%) required conversion to open procedures because of dense adhesions. Both of these patients had undergone and failed open antireflux Nissen fundoplications. Wrap failure was found in 2 (7%) patients failing open fundoplication and in 5 (18%) patients after laparoscopic fundoplications. Breakdown of the hiatal reconstruction led to revision in 6 (21%) patients after open fundoplications and 2 (7%) after laparoscopic fundoplications. Seven (25%) more patients failing open operations and 3 (10%) patients failing laparoscopic antireflux operations presented with failure of both the hiatal reconstruction and fundoplication wrap. Slipped Nissen was present in 2 (7%) patients failing open fundoplications, and wrap stricture after laparoscopic fundoplication led to revision in 1 (3%) patient (Table 1). Of the 5 patients failing fundoplications undertaken
at our institution, 4 had been undertaken laparoscopically and 1 with the open technique. Of the 4 failed laparoscopic fundoplications, wrap failure was responsible for failure in 1 patient, isolated hiatus failure in 2 patients, and combined hiatus and wrap failure in the 4th patient. The patient failing open fundoplication demonstrated failure of hiatus and unwinding of the wrap. According to the technique described previously, 23 patients (82%) underwent Nissen fundoplication (22 operations were completed laparoscopically and 1 required conversion to an open procedure). Five patients (18%) underwent partial fundoplications because of esophageal dysmotility. Four of these procedures were completed laparoscopically and 1 required conversion to an open technique (3 laparoscopic posterior fundoplication, 1 laparoscopic anterior fundoplication, and 1 laparoscopic posterior fundoplication converted to an open procedure). One patient underwent concomitant percutaneous tracheostomy due to poor pulmonary function, and 1 patient underwent concomitant cholecystectomy because of known symptomatic cholelithiasis. Inadvertent intraoperative events occurred in 13 patients (46%), in 9 patients during laparoscopic revision of failed open antireflux operations and in 4 patients during laparoscopic reoperation for failed primary laparoscopic fundoplications. The intraoperative events included isolated pneumothoraces in 2 patients, isolated gastrotomies in 5 patients, multiple enterotomies (more than one gastrotomy or gastrotomy associated with esophagotomy) in 5 patients, and splenic injury in 1 patient requiring four RBC transfusions. Four of the 5 (80%) patients who suffered inadvertent multiple enterotomies also had pleural injuries (Table 2). The median intraoperative blood loss was 50 ml (20 – 1000 ml). The median intraoperative blood loss for patients who underwent laparoscopic revisions of an open fundoplications was 62 ml (range 20 – 400 ml) and 50 ml (range 20 –1000 ml) for patients undergoing laparoscopic revisions of laparoscopic fundoplications. The mean length of the operation was 203 min ⫾ 66. The mean operative time to complete laparoscopic reoperative fundoplication was 216 min ⫾ 67 for patients after previous open antireflux procedures and 184 TABLE 2 Unanticipated Events Occurring in Thirteen Patients during Laparoscopic Revisions of Failed Antireflux Procedures Complication
Laparoscopic
Open
Gastrotomy Esophagotomy Pneumothorax Bleeding
3 0 2 1
7 1 4 0
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min ⫾ 64 for patients failing primary laparoscopic fundoplications. Postoperative complications occurred in six patients (21%). These included esophageal or gastric leaks in three (10%) patients (two after laparoscopic revision of open antireflux operations and one after revision of primary laparoscopic fundoplication), intrabdominal hematoma requiring surgical evacuation in one (3%) patient, myocardial infarction in one patient (3%), and cerebrovascular accident in one patient (3%). The esophagogastric leaks were managed nonoperatively in one patient and with surgical drainage and decortication in the other two patients (thoracoscopy in one patient, thoracotomy in one patient). No fatalities occurred in our series. The median hospital stay was 5 days (range 2–90). The median hospital stay in patients undergoing laparoscopic revision of failed open antireflux surgeries was 5 days (1–90 days), compared to 2.5 days (2–28 days) for patients undergoing laparoscopic revisions of failed laparoscopic fundoplications. The median hospital stay for patients who sustained intraoperative inadvertent events during reoperative laparoscopic fundoplication was 7 days (3–90 days) compared to 2 days (1– 60 days) for patients with uneventful laparoscopic revisions. At a mean follow-up of 20 months ⫾ 14, 25 patients (89%) are free from symptoms of gastroesophageal reflux and are off all preoperative antireflux medications. Three (11%) patients had recurrent heartburn and further workup demonstrated failure of the revised fundoplications. One patient has already undergone revision of her fundoplication revision through an open Toupet fundoplication. The other two patients did not consent to further operations. One additional patient had an esophageal stricture following a leak. This was treated with endoscopic dilation, and she is now able to eat without difficulties. DISCUSSION
The role of laparoscopy in the treatment of failed antireflux procedures is not well established. While several recent reports have documented the utility and efficacy of laparoscopic reoperative antireflux surgery, the risks associated with reoperative laparoscopic fundoplications are not well documented [10 –13]. This study reports the results of reoperative laparoscopic fundoplications undertaken for failed antireflux procedures and focuses on the differences in outcomes and risks of laparoscopic revisions of open antireflux operations and of laparosopic revisions of primary laparoscopic fundoplications. Over 5 years we undertook laparoscopic reoperations in a relatively small number of patients failing antireflux procedures constructed with an open or laparoscopic technique. These patients were generally older females, often with several comorbidities (coronary ar-
tery disease, asthma, COPD). More than two-thirds of the patients were referred from outside facilities, and more than two-thirds of the primary antireflux operations had been constructed with open techniques. A small number of patients had undergone multiple previous antireflux procedures. In general, the previous antireflux operations had been undertaken more than a year earlier. Patients were evaluated because of recurrent symptoms of GERD or dysphagia refractory to antireflux medications, considering them suspicious for failure of their original antireflux operation. Diagnosis of failure of their original fundoplication was undertaken only with abnormal findings on UGI contrast study, 24-h ambulatory pH study, manometry, and/or endoscopy. The UGI contrast study is the first, and most important, piece of information used to define failure of an antireflux operation. Additionally, the UGI contrast study undertaken in a 15° head-down position will provide useful information on anatomy and function of the esophagus, which will ultimately determine the type of fundoplication constructed at reoperation (total versus partial). As well, esophageal manometry can objectively determine the propulsive strength of the esophagus and may give useful information helpful in tailoring the antireflux operation to achieve the best outcome, although the interpretation of subtle manometric abnormalities in esophageal function can be difficult. With symptoms of GERD or dysphagia and normal UGI contrast study consistent with previous antireflux surgery, determination of the De Meester score by 24-h ambulatory pH study is appropriate. The causes of failure of primary antireflux operations were different for open and laparoscopic procedures. Additionally, the location where the primary operation had been undertaken influenced also the mechanism of failure of the antireflux procedure. For example, patients failing laparoscopic antireflux operations originally undertaken at our institution most frequently presented with breakdown of the hiatal reconstruction, whereas patients failing laparoscopic fundoplications constructed at outside facilities most frequently presented with failure of the wrap (completely or partially undone). This last finding is in contrast to most published literature, and it is probably due to inadequate laparoscopic techniques. On the other hand, failure of open antireflux operations was more frequently due to disruption of the hiatal reconstruction, and failure of laparoscopic fundoplications was more frequently associated with unwinding of the wrap. The mechanisms of disruption of the hiatus closure are not entirely understood. However, a wellconstructed wrap with a poorly mobilized esophagus, because of tension, could result in herniation of the fundoplication into the chest. We think that at the time of initial fundoplication it is necessary to mobilize the
SERAFINI ET AL.: LAPAROSCOPIC REOPERATIVE FUNDOPLICATION
esophagus sufficiently to reestablish at least 6 to 8 cm of intraabdominal esophagus and we believe that the laparoscopic approach easily allows this. Obesity and, in general, circumstances associated with increased abdominal pressure may also facilitate esophageal hiatus breakdown. Technical errors, such as poor approximation of the diaphragmatic crura or poor purchases through the muscles, inevitably lead to failure of the hiatal reconstruction. The esophageal hiatus should be closed appropriately snugly on the esophagus and the wrap should be anchored to the diaphragm to minimize the chances for herniation of the wrap into the chest, particularly early after surgery before scarring can develop. Even in the absence of notable hiatal hernia, we always oppose the crura with at least one stitch, assuming that our dissection has disrupted the phrenoesophageal membrane, predisposing it to later hiatal disruption and hernia formation. As previously stated, wrap failure was a common intraoperative finding after laparoscopic fundoplication, particularly after laparoscopic fundoplications undertaken at outside hospitals. Early in the experience with laparoscopic antireflux surgery, division of the short gastric vessels was not perceived essential and was felt to be technically challenging by many surgeons. We believe that division of the short gastric vessels is very important. Inadequate mobilization of the gastric fundus allows tension along the wrap, ultimately promoting unwinding of the fundoplication. Small tissue purchases at the time of the construction of the wrap can constitute another reason for failure of the wrap. Intraoperative inadvertent events, such as gastrotomies, esophagotomies, pneumothoraces, and splenic injuries, occurred more frequently in patients undergoing revision of failed open antireflux operations. This was probably related to increased technical difficulties related to dense adhesions. The increased technical difficulty is also reflected in longer operating times and higher blood loss occurring in patients undergoing revisions of open fundoplications. The conversion rate for reoperative laparoscopic fundoplications is generally reported to be near 10% (0 – 20%) [10 –15]. Eight percent of our patients required intraoperative conversion from laparoscopic to open fundoplication because of the inability of adequately identifying the anatomy due to dense adhesions. Length of hospital stay is generally reported to be around 3 days (2–5 days) [10 –15]. The median hospital stay of our patients was 5 days. However, in our series, hospital stay was prolonged in patients experiencing inadvertent intraoperative enterotomies. As well, hospital stay was found to be longer in patients undergoing laparoscopic revision of failed open antireflux operations compared to those patients undergoing laparoscopic revision of primary laparoscopic proce-
17
dures, primarily due to an increased occurrence of intraoperative gastrotomies. These results demonstrate that laparoscopic reoperation for failed antireflux surgery, although challenging, can be undertaken with minimally invasive techniques. Accurate selection of the patients for such operation will provide the best outcomes. Patients presenting after fundoplication with mild symptoms of reflux or occasional dysphagia should not be considered for reoperation if their symptoms are well controlled by adjunctive medications. On the other hand, those patients presenting with severe symptoms of reflux or dysphagia after fundoplication and demonstrating abnormal results at UGI contrast study or 24-h ambulatory pH study should be considered candidates for laparoscopic reoperative antireflux surgery. We believe that laparoscopic revision of open fundoplications was substantially more challenging and more prone to complications than laparoscopic revisions of laparoscopic fundoplications. Although “difficulty” cannot be quantified directly, measures of difficulty, such as length of the operation and intraoperative blood loss, were significantly higher in patients requiring revision of open fundoplications. Redo laparoscopic fundoplications should be undertaken following the same steps of primary laparoscopic fundoplications, with careful definition of the anatomy, adequate mobilization of the esophagus, and construction of an adequate wrap. From our experience with laparoscopic revision of failed antireflux procedures, we have learned many lessons. The first and foremost lesson learned is that antireflux procedures need to be undertaken with great care and attention to operative details the first time. Such care and attention will help to minimize the number of failures and need for reoperations. Laparoscopic reoperative antireflux surgeries can be technically easier and less prone to complications when undertaken in patients failing primary laparoscopic fundoplications as opposed to primary open fundoplications. However, because of the difficulty of laparoscopic reoperations and the possibility of serious complications causing potentially prolonged hospital stays, the diagnosis of failure of antireflux operations and the indications for laparoscopic reoperative fundoplication must be defined upon abnormal UGI contrast study or 24-h ambulatory pH study. Ultimately, the need for reoperative laparoscopic antireflux surgery must always be carefully weighed against procedure-related and patient-specific risks (e.g., cardiac diseases, pulmonary diseases). REFERENCES 1. 2.
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