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Surgical treatment after the failed antireflux operation
J
THoRAc CARDIOVASC SURG
92:667-672, 1986
Surgical treatment after the failed antireflux operation Eighty-seven adults bave undergone reoperation for recurrent gastroesopbageal reflux or complications of prior antireflux procedures. Operations performed included the transthoracic Collis-Nissen procedure (59), Collis-Belsey repair (14), Nissen fundoplication (one), repair of acute postoperative paraesopbageal hernia (one), division of obstructing crural suture (one), and esopbageal resection (23). Among the 73 patients undergoing an additional hiatal hernia repair, there were two postoperative deaths. Follow-up averages 28 months. Subjectively, results bave been excellent or good (no or mild reflux symptoms or dyspbagia) in 47 (67 % ~ fair in eight (12 %), who bave moderate dyspbagia or reflux symptoms controlled medically; and poor in 15 (21 %), 12 of whom bave required additional operations. Early postoperative esopbageal dilations were required in 25 patients (36%) and regular dilations in seven (10% ~ Among the 23 patients undergoing esopbageal resection, four bad a distal esopbagectomy and short-segment colon interposition and 19 bad a transhiatal esopbagectomy without thoracotomy; stomach was used for esopbageal replacement in 14 and colon in five. There were no operative deaths. Follow-up averages 17 months. Thirteen patients bave bad esopbageal dilations (nine early and four regularly), and one has clinically significant reflux. Overall, subjective results are good or excellent in 64 (76%). The results of "redo hiatal hernia operation" are far from ideal. Optimal surgical treatment after the failed antireflux operation requires careful analysis of the existing anatomy and experience to decide when esopbageal resection is a safer and more reliable approach than another hiatal hernia repair.
Mack C. Stirling, M.D. (by invitation), and Mark B. Orringer, M.D., Ann Arbor, Mich.
Long-term control of gastroesophageal reflux, without inflicting new adverse symptoms, is the goal of every antireflux operation, and controversy exists as to which surgical approach is best at achieving this. Current reports indicate that successful reflux control is achieved in approximately 85% to 90% of patients undergoing operation, whereas additional untoward symptoms, not necessarily related to reflux, develop in 10% to 12%. Thus an antireflux operation may fail because recurrent gastroesophageal reflux, dysphagia, gas bloat syndrome, or other complications of the operation develop. The operative management of the patient with a failed antireflux procedure is a major clinical challenge, and there are few reports that study the problem in detail. This paper reviews our experience with patients with From the Section of Thoracic Surgery, Department of Surgery, University of Michigan Hospitals, Ann Arbor, Mich. Read at the Sixty-sixth Annual Meeting of The American Association for Thoracic Surgery. New York, N. Y., April 28-30, 1986. Address for reprints: Mark B. Orringer, M.D., Section of Thoracic Surgery, University of Michigan Hospitals, TC-2120/0344, 1500 E. Medical Center Dr., Ann Arbor, Mich. 48109.
failed antireflux operations treated between 1974 and 1985 on the University of Michigan Thoracic Surgery Service. Patients and methods The medical records of 87 patients operated on between 1974 and 1985 for a failed antireflux operation were reviewed retrospectively. Fifty-one (59%) were men and 36 (41 %) were women. The average age was 48 years (range 22 to 77 years). Sixty-two patients (72%) had undergone one previous antireflux operation; 21 patients (24%), two; three patients (3%), three; and one patient (1%), four previous antireflux operations. Of the 117 total previous hiatal hernia repairs, 61 were transthoracic and included 39 nonspecified, 14 Belsey, six Collis-Belsey, one Collis-Nissen, and one Nissen. There were 56 transabdominal repairs, including 35 nonspecified, 11 Nissen, eight Hill, and two Angelchik prostheses. The average interval from the most recent failed antireflux operation to treatment at the University of Michigan was 64 months (range 0 to 360 months). In addition to sequelae of gastroesophageal reflux, two 667
The Journal of Thoracic and Cardiovascular Surgery
6 6 8 Stirling and Orringer
Table I. Subjective results of operations for failed antireflux procedures Collis-Belsey In = 13) No. Reflux* None Mild Moderate Severe
7 3 I
2
Collis-Nissen In = 55)
I
Esophagectomy In = 23)
%
No.
54% } 770/, 23% 0 8% 15%
44 4 I 6
8~~
3~~ }
24 6 19 6
~~~ } 55%
21 16 6 12
~~~
I
%
} 87%
2% 11%
No.
I
%
17 5 I 0
74% } 960/, 22% 0 4%
6 4 9 4
27% } 440/, 17% 0 39% 17%
5 10 6 2
22% } 650/, 43% 0 26% 9%
Dysphagia] None Mild Moderate Severe Overallf Excellent
Good Fair Poor
5 1 6 I
2 6 2 3
46%
46% 8%
~:~ } 62% 15% 23%
34% 11%
11% 22%
} 67%
'Reflux: mild: requires no treatment; moderate: controlled by medical therapy; severe: uncontrolled by medication or need for rcoperation. tDysphagia: mild: requires no treatment; moderate: requires occasional dilation; severe: regular dilations or need for reoperation. tOverall: excellent: asymptomatic; good : minimal symptoms necessitating no treatment; fair: symptoms controlled by medication or dilation; poor: symptoms uncontrolled, reoperation needed.
patients had scleroderma and two patients had undergone division of a congenital tracheoesophageal fistula and primary repair of esophageal atresia in infancy, The most common symptoms in these patients were heartburn in 64 (74%), regurgitation in 54 (62%), and dysphagia in 39 patients (45%), which was graded as mild (intermittent and necessitating no dilations) in 20 or severe (necessitating dilations) in 19. Additional symptoms included weight loss of more than 10 pounds in 24 patients (28%), aspiration in II (13%), spasm in eight (9%), gross gastrointestinal bleeding in six (7%), and the gas bloat syndrome in two (2%). Preoperative barium esophagograms were obtained in all patients. Sixty-three (72%) had a recurrent hiatal hernia. Fifty (57%) of these hernias were sliding, eight (9%) paraesophageal, and five (6%) combined. Gastroesophageal reflux was seen radiographically in 27 patients (31%) and stricture or obstruction in 18 (21%). Preoperative endoscopy was performed in all but three patients with incarcerated paraesophageal hernias. Sixty-five patients (77%) had some degree of esophagitis: grade I (erythema) in nine (11%); grade II (ulceration) in 39 (46%); grade III (ulceration with dilatable stricture) in 14 (17%); and grade IV (ulceration with undilatable stricture) in three (3%). Three patients had extrinsic distal esophageal obstruction, two from Angelchik prostheses and one from too tight a Nissen fundoplication.
Esophageal function tests, including manometry and standard intraesophageal acid reflux testing, were performed in 81 patients preoperatively. Abnormal (2 to 3+) acid reflux was documented in 68 (84%). Average peak pressure in the distal esophageal high-pressure zone (HPZ) was 5.0 ± 5.4 mm Hg, and HPZ length averaged 2.1 ± 1.9 em. In addition to having periesophagitis from their prior esophageal operation and reflux esophagitis, 40 of the 87 patients had at least one associated condition that was believed to predispose to recurrent gastroesophageal reflux after any of the standard antireflux repairs. Eleven (13%) were markedly obese and 15 (17%) had chronic obstructive pulmonary disease. Twenty-four (28%) had a history of either an abdominal incisional hernia (II patients) or an inguinal hernia (eight single, five either multiple or recurrent). Two patients were on steroid therapy and two had associated bronchogenic carcinoma. Of the 87 patients undergoing reoperation for failed hiatal hernia repairs, 14 were treated with a combined Collis gastroplasty-Belsey repair as described previously,' 57 underwent a combined Collis-Nissen fundoplication procedure as described previously,' and 14 underwent esophageal resection. One patient underwent repair of an acute postoperative paraesophageal hernia after a posterior crural repair disruption, and one had a transabdominal reconstruction of an overly tight Nissen fundoplication. In addition, nine patients who were
Volume 92 Number 4 October 1986
Failed antireflux operation
669
Table II. Esophageal function tests after combined Collis gastroplasty-fundoplication operations for failed antireflux procedures Collis-Belsey
Acid reflux test Normal (0-1+) Abnormal (2-3+) High-pressure zone Pressure (mm Hg) Length (em)
Preop. In = 13)
1 yr (n » 12)
2-6 yr In = 8)
I ( 8%) 12 (92%)
7 (58%) 5 (42%)
4 (50%) 4 (50%)
6.2 ± 7.1 \.5 ± \.8
8.9 ± 2.0 3.5 ± \.0
8.0 ± 1.7 2.9 ± 0.60
Collis-Nissen
Acid reflux test Normal (0-1+) Abnormal (2-3+) High-pressure zone Pressure (mm Hg) Length (em)
Preop. In = 56)
1 yr In = 39)
2-6 yr In = 13)
9 (16%) 47 (84%)
36 (92%) 3 ( 8%)
12 (92%) I ( 8%)
4.9 ± 5.6 2.3 ± 2.0
I\.6 ± 3.4 4.3 ± 1.3
10.2 ± 2.8 3.6 ± .90
treated with a Collis-Nissen hiatal hernia repair ultimately required an esophageal resection. In this subgroup of 23 patients with failed antireflux operations treated with resection, 18 (78%) had had at least two hiatal hernia repairs, eight (34%) had reflux strictures, and six (26%) had significant subjective complaints of esophageal spasm. Both patients with scleroderma reflux esophagitis and both patients with a history of esophageal atresia required esophagectomy after unsuccessful prior antireflux operations. Two patients who had had a distal esophageal leak after a Collis-Nissen hiatal hernia repair for a failed antireflux procedure developed a stricture that necessitated esophagectomy.
Results Early in our experience, Collis-Belsey repairs were performed in 14 patients with recurrent reflux. In six of these, a pyloromyotomy was added because of the possibility of intraoperative vagal nerve damage, and a diaphragmatic counterincision was required in four. One patient died of sequelae of a subsequent subphrenic abscess. Complications occurred in eight patients (57%) and included distal esophageal leaks (two), wound infections (two), abdominal incisional hernia (one), subphrenic abscess (one), splenectomy for intraoperative trauma (one), and intra-abdominal hemorrhage from a divided short gastric vessel (one). Average hospital stay was 18 days (range 9 to 66 days). Follow-up averages 41 months (0 to 108 months) for the 13 survivors.Seventyseven percent have either no or minimal subjective reflux (Table I). However, only 58% and 50% had
objective reflux control at I year and later follow-up, respectively (Table 11). Preoperatively, three patients had dysphagia necessitating dilation therapy. Postoperatively, all three of these patients required at least occasional dilations, as did four additional patients after their Collis-Belsey repair. Sixty-two percent of the Collis-Belsey patients had either an excellent or good symptomatic result and required no further therapy at the most recent follow-up. Two subsequently underwent Collis-Nissen procedures for recurrent reflux esophagitis; one had a good result and one had a poor result. Among the 57 patients who were treated with a Collis-Nissen repair, a pyloromyotomy was performed in 13 (23%) and a diaphragmatic counterincision was required in 12 (21%). One patient who had an incarcerated paraesophageal hernia after a previous hiatal hernia repair died of sequelae of a small bowel obstruction after his Collis-Nissen operation. There were complications in 11 patients (19%): splenectomy necessitated by intraoperative trauma (two), postoperative hemorrhage (three), distal esophageal leak (two), abdominal wound dehiscence (one), small bowel obstruction (one), pulmonary embolus (one), and chylothorax (one). Average hospital stay was 13 days (range 7 to 68 days). One patient was lost to follow-up. Follow-upaverages 25 months (1 to 118 months) for the remaining 55 patients. Eighty-seven percent have no or minimal subjective reflux (Table I). The standard acid reflux test has objectively demonstrated good control of reflux in 92% of the patients postoperatively (Table II). However, in five patients with reflux symptoms and
670
The Journal of Thoracic and Cardiovascular Surgery
Stirling and Orringer
normal standard acid reflux test results, 24 hour monitoring of distal esophageal pH has demonstrated abnormal reflux (at 1 year in four patients and at 3 years in one patient). Preoperatively, eight patients had dysphagia necessitating dilation therapy. Five of these eight and an additional 20 patients required at least occasional dilations after their Collis-Nissen repair. At most recent follow-up, 67% had either an excellent or good result, requiring no treatment for either reflux or dysphagia. Eleven percent had a fair result, with dysphagia or reflux controlled by dilations or antacids. Of the 12 patients (22%) with poor results, 10 have had a subsequent operation. In one patient with severe dysphagia from an overly aggressive crural approximation, cutting a single suture gave an excellent result. The other nine patients underwent esophageal resection and their results are analyzed later in this report. Twenty-three patients (14 initially and nine after a failed Collis-Nissen operation) underwent esophageal resection as treatment of a failed antireflux operation. Four patients had a distal esophagectomy and shortsegment colon interposition, and 19 underwent a transhiatal esophagectomy without thoracotomy; 14 had esophageal replacement with stomach and five with colon. There were no operative deaths. Complications occurred in five patients (22%): cervical anastomotic leak, wound infection, small bowel obstruction, abdominal abscess, and aspiration in one each. Average hospital stay was 15 days (range 8 to 53 days). Follow-up averages 17 months (l to 84 months). Only one patient has symptomatic reflux necessitating treatment (Table I). Preoperatively, 12 of these patients had dysphagia necessitating dilation therapy. Postoperatively, three of these 12 and an additional 10 patients required at least occasional dilations after their esophagectomy. At latest follow-up, 65% have had either a good or excellent subjective response, having neither significant reflux symptoms nor dysphagia. One patient had dysphagia from a previous too tight Nissen fundoplication. The wrap was redone transabdominally with good results. In a final patient, a barium swallow 1 week after a Collis-Nissen procedure revealed an asymptomatic paraesophageal hernia caused by disruption of the crural repair. The hernia was reduced and the crural repair redoen with good results. These 87 patients underwent 99 operations to treat recurrent reflux or dysphagia after previous antireflux operations. Ten additional operations were required for complications. Overall operative mortality was 2% (two deaths). One patient has been lost to follow-up. Subjectively, 64 patients (76%) have had either good or excellent results (are either asymptomatic or have
minimal symptoms necessitating no treatment); 14 (17%), fair results (symptoms are controlled by medication or dilations); and six patients (7%), poor results (symptoms are uncontrolled). Among these patients, mild postoperative gas bloat syndrome has occurred once after a Coilis-Nissen repair, and mild dumping syndrome has occurred six times, three times after a Collis-Nissen repair and three times after esophagectomy. Discussion
Patients with failed antireflux operations constitute a major clinical challenge. The true magnitude of this problem is difficult to assess, because most patients who have antireflux procedures do not have adequate objective long-term follow-up. Current clinical reports,"? many based on subjective questioning of patients, indicate that after various "hiatal hernia" repairs, reflux is not controlled in 10% to 15% of the patients, and new symptoms not necessarily related to reflux develop in 10%to 25%. It is probable that poor operative results are even more common than these large reported series would suggest. The challenge is to identify those operative principles that are most critical to minimizing failure of the initial antireflux procedure. Regardless of the type of repair, the gastroesophageal junction must be identified accurately and mobilized completely so that reduction of a 3 to 5 em segment of distal esophagus belowthe diaphragmatic hiatus is achieved. Avoidance of tension on the repair is as critical at the diaphragmatic hiatus as it is in the repair on every abdominal wall hernia. To minimize postoperative dysphagia after a fundoplication, the wrap should be performed with a large dilator (54 Fr. or larger) across the esophagogastric junction. Approximation of the crura behind the esophagus ensures that the repair remains in the abdomen, but adequates bites of crural musculature and tendinous diaphragm must be taken if the crural reconstruction is to last. Acute postoperative events that stress the repair, such as violent involuntary "bucking" against the endotracheal tube by the semiconscious patient or gastric distention, must be avoided. The concept of "recurrence risk factors" I seems valid. Certain patients undergoing any antireflux operation have identifiable factors that predispose them to disruption of their repair and recurrent reflux. For example, 13% of our patients were marked obese and 17% had chronic obstructive pulmonary disease, both conditions that increase intra-abdominal pressure and tension on the diaphragmatic repair. In addition, the high incidence of inguinal (15%) and abdominal wall (13%) hernias in our patients suggests
Volume 92 Number 4 October 1986
that some recurrences may be related to intrinsic connective tissue weakness. We consider patients with failed antireflux operations to be at special risk for recurrence with subsequent standard repairs, because the periesophageal reaction that results from prior operation at the esophagogastric junction prevents the accurate placement of the fundoplication esophageal sutures into healthy esophageal muscle and submucosa. Placement of sutures into a distal esophagus that is shortened and inflamed by reflux esophagitis is suboptimal. As a rule, surgeons who prefer the Belsey, Nissen, or Hill repair for the initial treatment of gastroesophageal reflux, when confronted with a patient with recurrent reflux, simply advocate redoing "their" operation. It is usually, but by no means always, possible to redo a hiatal hernia operation at least once. Our current preference is to perform the combined esophaguslengthening Collis gastroplasty-Nissen fundoplication procedure, which ensures a tension-free repair and provides a healthy "neoesophagus" of resilient stomach rather than inflamed or scarred distal esophagus around which to perform the fundoplication. Certain details of redo antireflux operations warrant emphasis. A transthoracic approach is usually preferred for reoperative antireflux operations when another antireflux operation is likely. Adequate esophageal mobilization is not possible through the abdomen. If the problem is purely intra-abdominal (e.g., too tight a Nissen fundoplication), an abdominal approach to redo the wrap is advised. Placement of an intraesophageal dilator (40 Fr. or larger) within the esophagus facilitates its identification within mediastinal scar tissue. When mobilizing the stomach and esophagus, the surgeon should conscientiously "dissect wide," if necessary taking a thin layer of diaphragm or liver capsule to avoid devascularization of the gastric fundus. If after mobilization there is extensive disruption or devascularization of the esophagus or stomach, resection and visceral esophageal substitution is far safer than attempted local repair and repeat fundoplication. The colon is routinely prepared preoperatively in the event that it is needed for esophageal replacement. Whether it is preferable to resect only the distal esophagus and perform a short-segment left colon" or jejunal interposition" or to remove the entire thoracic esophagus and perform a cervical esophageal anastomosis to avoid the potential complications of an intrathoracic anastomostic leak'? II is still debatable. A contused cardia, which may follow takedown of a previous hiatal hernia repair, may be unsuitable for a repeat fundoplication, but does not necessarily preclude use of the stomach as an esophageal replacement and a cervical
Failed antireflux operation
671
esophagogastric anastomosis. The devitalized portion of stomach may often be resected by stapling along the lesser curvature, providing a relatively healthy "tube" of greater curvature that readily reaches to the neck. A distal esophageal resection with intrathoracic esophagogastric anastomosis should virtually never be done in this setting because reflux esophagitis will develop after this procedure in at least 40% of patients. The proper selection of patients for esophageal resection requires judgment and experience. Those with nondilatable strictures or persistent fistulas at the esophagogastric junction after a prior antireflux operation usually require resection. However, rules of thumb regarding the need for esophageal resection based purely upon the number of previous unsuccessful antireflux operations are misleading. The type of previous procedure(s) has far more significance in influencing our decision for another attempt at an antireflux operation versus resection. For example, many patients with a history of previous unspecified "anatomic hiatal hernia" operations performed 15 to 30 years ago may have had little more than simple crural approximation, with minimal periesophageal or perihiatal reaction and a virtually "virgin" esophagogastric junction that is readily amenable to reconstruction. Alternatively, in the patient who has undergone a combined gastroplastyfundoplication operation, takedown of the repair for revision is often impossible, and resection is the only alternative. The decision for the type of redo operation, then, must be individualized and is based upon the surgeon's degree of experience, his preoperative assessment of the barium swallow, the results of endoscopy, and the findings at operation. Esophageal resection is indicated in patients with nondilatable strictures (including those that disrupt during attempted intraoperative dilation), those with chronic esophageal fistulas after prior repairs, and those in whom the fundus cannot be taken down after a previous fundoplication or is devascularized in the process of mobilization. We'? II currently advocate a transhiatal esophagectomy without thoracotomy and cervical esophagogastrostomy in patients in whom the need for esophageal resection is determined preoperatively. Symptoms of reflux esophagitis are eliminated when the esophagus is resected, and the patient with a cervical esophagogastric anastomosis has virtually no clinically significant reflux. Postoperative dysphagia from stenosis of the cervical esophagogastric anastomosis is minimized by construction of the anastomosis over a 46 Fr. or larger intraesophageal dilator. Other clinical reports" 12-16 of the surgical treatment of failed antireflux procedures describe good or excellent results in 66% to 90% of patients treated with a variety
The Journal of
6 7 2 Stirling and Orringer
of hiatal hernia repairs and esophageal resection. Good or excellent results were obtained in 76% of our 87 patients, 12 (14%) of whom required a second operation. Our data and those of others indicate that the results of surgical treatment for failed antireflux operations are far from idea. There is a critical need to determine if the concept of "recurrence risk factors" is valid; that is, is it possible to identify preoperatively those patients who are more likely to have a poor result from a standard antireflux procedure? If so, are there specific operative techniques, such as the Collis gastroplasty, that can minimize the incidence of recurrence so that fewer patients must be considered for redo operations?
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4
5
6
7
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II 12
Thoracic and Cardiovascular Surgery
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for disruption and recurrence after Nissen fundoplication. Arch Surg 114:542-548, 1979 Leonardi HK, Crozier RE, Ellis FH: Reoperation for complications of the Nissen fundoplication. J THoRAe CARDIOVASC SURG 81:50-56, 1981 Maher JW, Hocking MP, Woodward ER: Reoperations for esophagitis following failed antireflux procedures. Ann Surg 201:723-727, 1985 Zueker K, Reskin GW, Saik RP: Recurrent hital hernia repair. Arch Surg 117:413-414, 1982 Little AG, Ferguson MK, Skinner DB: Reoperation for failed antireflux operations. J THORAC CARDIOVASC SURG 91:511-517,1986
Discussion
REFERENCES
DR. ROBERT D. HENDERSON
Orringer MB, Sloan HS: Collis-Belsey reconstruction of the esophagogastric junction. J THORAC CARDIOVASC SURG 71:295-303, 1976 Orringer MB, Sloan H: Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 25:16-21,1978 Hiebert CA, O'Mara CS: The Belsey operation for hiatal hernia. A twenty year experience. Am J Surg 13:532-535, 1979 Negre JB: Post-fundoplication symptoms. Do they restrict the success of Nissen fundoplication? Ann Surg 198:698700, 1983 Negre JB, Marakula HT, Keyrilainen 0, Matisainen M: Nissen fundoplication. Results at 10 year follow-up. Am 1 Surg 146:635-637, 1983 Orringer MB, Skinner DB, Belsey RHR: Long-term results of the Mark IV operation for hiatal hernia and analysis of recurrences and their treatment. J THORAC CARDIOVASC SURG 63:25-31, 1972 Polk HC Jr: Fundoplication for reflux esophagitis. Misadventures with the operation of choice. Ann Surg 182:645652, 1976 Belsey RHR: Reconstruction of the esophagus with left colon. J THORAC CARDIOVASC SURG 49:33-55, 1965 Polk HC: Jejunal interposition for reflux esophagitis and esophageal stricture unresponsive to valvuloplasty. Would J Surg 4:731-736, 1980 Orringer MB: Technical aids in performing transhiatal esophagectomy without thoracotomy. Ann Thorac Surg 38: 128-132, 1984 Orringer MB: Transhiatal esophagectomy for benign disease. J THORAC CARDIOVASC SURG 90:649-655, 1985 Hill LD, Riivo I, Stevenson JK, Pearson JM: Reoperation
Toronto. Ontario. Canada
I have had a particular interest in revision esophageal surgery that can be illustrated by examining two groups of patients. The first study comprises 335 consecutive patients treated by total fundoplication gastroplasty (TFG). The second group of 190 are patients with previous esophageal operations who are treated by thoracoabdominal TFG with pyloromyotomy. Both groups have been followed up for a minimum of 5 years. In the first group 93.1% are eating normally, 3.9% have moderate residual symptoms, and 3% have persistence or recurrence of major symptoms. According to the same classification, 86.8% of patients requiring revision TFG asymptomatic, 7.9% have minor residual symptoms, 4.7% major symptoms, and one patient (0.5) died. Further analysis shows that in patients with both patients gastric and esophageal operations there is a slight further deterioration of the results achieved. These results demonstrate that, despite the increased technical difficulty of redo operations, satisfactory results can still be achieved. DR. STIRLING (Closing) We appreciate Dr. Henderson's comments and acknowledge his extensive experience with this problem. His results suggest that previous gastric surgery should be added to the list of recurrence risk factors. In closing, we would like to emphasize our dissatisfaction with the results of reoperative antireflux operations. A 24% failure rate for benign disease is clearly unsatisfactory. These results will be improved only by identifying patients predisposed to recurrence and by modifying surgical techniques to minimize subsequent failure after standard repairs.
THoRAc CARDIOVASC SURG
92:667-672, 1986
Surgical treatment after the failed antireflux operation Eighty-seven adults bave undergone reoperation for recurrent gastroesopbageal reflux or complications of prior antireflux procedures. Operations performed included the transthoracic Collis-Nissen procedure (59), Collis-Belsey repair (14), Nissen fundoplication (one), repair of acute postoperative paraesopbageal hernia (one), division of obstructing crural suture (one), and esopbageal resection (23). Among the 73 patients undergoing an additional hiatal hernia repair, there were two postoperative deaths. Follow-up averages 28 months. Subjectively, results bave been excellent or good (no or mild reflux symptoms or dyspbagia) in 47 (67 % ~ fair in eight (12 %), who bave moderate dyspbagia or reflux symptoms controlled medically; and poor in 15 (21 %), 12 of whom bave required additional operations. Early postoperative esopbageal dilations were required in 25 patients (36%) and regular dilations in seven (10% ~ Among the 23 patients undergoing esopbageal resection, four bad a distal esopbagectomy and short-segment colon interposition and 19 bad a transhiatal esopbagectomy without thoracotomy; stomach was used for esopbageal replacement in 14 and colon in five. There were no operative deaths. Follow-up averages 17 months. Thirteen patients bave bad esopbageal dilations (nine early and four regularly), and one has clinically significant reflux. Overall, subjective results are good or excellent in 64 (76%). The results of "redo hiatal hernia operation" are far from ideal. Optimal surgical treatment after the failed antireflux operation requires careful analysis of the existing anatomy and experience to decide when esopbageal resection is a safer and more reliable approach than another hiatal hernia repair.
Mack C. Stirling, M.D. (by invitation), and Mark B. Orringer, M.D., Ann Arbor, Mich.
Long-term control of gastroesophageal reflux, without inflicting new adverse symptoms, is the goal of every antireflux operation, and controversy exists as to which surgical approach is best at achieving this. Current reports indicate that successful reflux control is achieved in approximately 85% to 90% of patients undergoing operation, whereas additional untoward symptoms, not necessarily related to reflux, develop in 10% to 12%. Thus an antireflux operation may fail because recurrent gastroesophageal reflux, dysphagia, gas bloat syndrome, or other complications of the operation develop. The operative management of the patient with a failed antireflux procedure is a major clinical challenge, and there are few reports that study the problem in detail. This paper reviews our experience with patients with From the Section of Thoracic Surgery, Department of Surgery, University of Michigan Hospitals, Ann Arbor, Mich. Read at the Sixty-sixth Annual Meeting of The American Association for Thoracic Surgery. New York, N. Y., April 28-30, 1986. Address for reprints: Mark B. Orringer, M.D., Section of Thoracic Surgery, University of Michigan Hospitals, TC-2120/0344, 1500 E. Medical Center Dr., Ann Arbor, Mich. 48109.
failed antireflux operations treated between 1974 and 1985 on the University of Michigan Thoracic Surgery Service. Patients and methods The medical records of 87 patients operated on between 1974 and 1985 for a failed antireflux operation were reviewed retrospectively. Fifty-one (59%) were men and 36 (41 %) were women. The average age was 48 years (range 22 to 77 years). Sixty-two patients (72%) had undergone one previous antireflux operation; 21 patients (24%), two; three patients (3%), three; and one patient (1%), four previous antireflux operations. Of the 117 total previous hiatal hernia repairs, 61 were transthoracic and included 39 nonspecified, 14 Belsey, six Collis-Belsey, one Collis-Nissen, and one Nissen. There were 56 transabdominal repairs, including 35 nonspecified, 11 Nissen, eight Hill, and two Angelchik prostheses. The average interval from the most recent failed antireflux operation to treatment at the University of Michigan was 64 months (range 0 to 360 months). In addition to sequelae of gastroesophageal reflux, two 667
The Journal of Thoracic and Cardiovascular Surgery
6 6 8 Stirling and Orringer
Table I. Subjective results of operations for failed antireflux procedures Collis-Belsey In = 13) No. Reflux* None Mild Moderate Severe
7 3 I
2
Collis-Nissen In = 55)
I
Esophagectomy In = 23)
%
No.
54% } 770/, 23% 0 8% 15%
44 4 I 6
8~~
3~~ }
24 6 19 6
~~~ } 55%
21 16 6 12
~~~
I
%
} 87%
2% 11%
No.
I
%
17 5 I 0
74% } 960/, 22% 0 4%
6 4 9 4
27% } 440/, 17% 0 39% 17%
5 10 6 2
22% } 650/, 43% 0 26% 9%
Dysphagia] None Mild Moderate Severe Overallf Excellent
Good Fair Poor
5 1 6 I
2 6 2 3
46%
46% 8%
~:~ } 62% 15% 23%
34% 11%
11% 22%
} 67%
'Reflux: mild: requires no treatment; moderate: controlled by medical therapy; severe: uncontrolled by medication or need for rcoperation. tDysphagia: mild: requires no treatment; moderate: requires occasional dilation; severe: regular dilations or need for reoperation. tOverall: excellent: asymptomatic; good : minimal symptoms necessitating no treatment; fair: symptoms controlled by medication or dilation; poor: symptoms uncontrolled, reoperation needed.
patients had scleroderma and two patients had undergone division of a congenital tracheoesophageal fistula and primary repair of esophageal atresia in infancy, The most common symptoms in these patients were heartburn in 64 (74%), regurgitation in 54 (62%), and dysphagia in 39 patients (45%), which was graded as mild (intermittent and necessitating no dilations) in 20 or severe (necessitating dilations) in 19. Additional symptoms included weight loss of more than 10 pounds in 24 patients (28%), aspiration in II (13%), spasm in eight (9%), gross gastrointestinal bleeding in six (7%), and the gas bloat syndrome in two (2%). Preoperative barium esophagograms were obtained in all patients. Sixty-three (72%) had a recurrent hiatal hernia. Fifty (57%) of these hernias were sliding, eight (9%) paraesophageal, and five (6%) combined. Gastroesophageal reflux was seen radiographically in 27 patients (31%) and stricture or obstruction in 18 (21%). Preoperative endoscopy was performed in all but three patients with incarcerated paraesophageal hernias. Sixty-five patients (77%) had some degree of esophagitis: grade I (erythema) in nine (11%); grade II (ulceration) in 39 (46%); grade III (ulceration with dilatable stricture) in 14 (17%); and grade IV (ulceration with undilatable stricture) in three (3%). Three patients had extrinsic distal esophageal obstruction, two from Angelchik prostheses and one from too tight a Nissen fundoplication.
Esophageal function tests, including manometry and standard intraesophageal acid reflux testing, were performed in 81 patients preoperatively. Abnormal (2 to 3+) acid reflux was documented in 68 (84%). Average peak pressure in the distal esophageal high-pressure zone (HPZ) was 5.0 ± 5.4 mm Hg, and HPZ length averaged 2.1 ± 1.9 em. In addition to having periesophagitis from their prior esophageal operation and reflux esophagitis, 40 of the 87 patients had at least one associated condition that was believed to predispose to recurrent gastroesophageal reflux after any of the standard antireflux repairs. Eleven (13%) were markedly obese and 15 (17%) had chronic obstructive pulmonary disease. Twenty-four (28%) had a history of either an abdominal incisional hernia (II patients) or an inguinal hernia (eight single, five either multiple or recurrent). Two patients were on steroid therapy and two had associated bronchogenic carcinoma. Of the 87 patients undergoing reoperation for failed hiatal hernia repairs, 14 were treated with a combined Collis gastroplasty-Belsey repair as described previously,' 57 underwent a combined Collis-Nissen fundoplication procedure as described previously,' and 14 underwent esophageal resection. One patient underwent repair of an acute postoperative paraesophageal hernia after a posterior crural repair disruption, and one had a transabdominal reconstruction of an overly tight Nissen fundoplication. In addition, nine patients who were
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Table II. Esophageal function tests after combined Collis gastroplasty-fundoplication operations for failed antireflux procedures Collis-Belsey
Acid reflux test Normal (0-1+) Abnormal (2-3+) High-pressure zone Pressure (mm Hg) Length (em)
Preop. In = 13)
1 yr (n » 12)
2-6 yr In = 8)
I ( 8%) 12 (92%)
7 (58%) 5 (42%)
4 (50%) 4 (50%)
6.2 ± 7.1 \.5 ± \.8
8.9 ± 2.0 3.5 ± \.0
8.0 ± 1.7 2.9 ± 0.60
Collis-Nissen
Acid reflux test Normal (0-1+) Abnormal (2-3+) High-pressure zone Pressure (mm Hg) Length (em)
Preop. In = 56)
1 yr In = 39)
2-6 yr In = 13)
9 (16%) 47 (84%)
36 (92%) 3 ( 8%)
12 (92%) I ( 8%)
4.9 ± 5.6 2.3 ± 2.0
I\.6 ± 3.4 4.3 ± 1.3
10.2 ± 2.8 3.6 ± .90
treated with a Collis-Nissen hiatal hernia repair ultimately required an esophageal resection. In this subgroup of 23 patients with failed antireflux operations treated with resection, 18 (78%) had had at least two hiatal hernia repairs, eight (34%) had reflux strictures, and six (26%) had significant subjective complaints of esophageal spasm. Both patients with scleroderma reflux esophagitis and both patients with a history of esophageal atresia required esophagectomy after unsuccessful prior antireflux operations. Two patients who had had a distal esophageal leak after a Collis-Nissen hiatal hernia repair for a failed antireflux procedure developed a stricture that necessitated esophagectomy.
Results Early in our experience, Collis-Belsey repairs were performed in 14 patients with recurrent reflux. In six of these, a pyloromyotomy was added because of the possibility of intraoperative vagal nerve damage, and a diaphragmatic counterincision was required in four. One patient died of sequelae of a subsequent subphrenic abscess. Complications occurred in eight patients (57%) and included distal esophageal leaks (two), wound infections (two), abdominal incisional hernia (one), subphrenic abscess (one), splenectomy for intraoperative trauma (one), and intra-abdominal hemorrhage from a divided short gastric vessel (one). Average hospital stay was 18 days (range 9 to 66 days). Follow-up averages 41 months (0 to 108 months) for the 13 survivors.Seventyseven percent have either no or minimal subjective reflux (Table I). However, only 58% and 50% had
objective reflux control at I year and later follow-up, respectively (Table 11). Preoperatively, three patients had dysphagia necessitating dilation therapy. Postoperatively, all three of these patients required at least occasional dilations, as did four additional patients after their Collis-Belsey repair. Sixty-two percent of the Collis-Belsey patients had either an excellent or good symptomatic result and required no further therapy at the most recent follow-up. Two subsequently underwent Collis-Nissen procedures for recurrent reflux esophagitis; one had a good result and one had a poor result. Among the 57 patients who were treated with a Collis-Nissen repair, a pyloromyotomy was performed in 13 (23%) and a diaphragmatic counterincision was required in 12 (21%). One patient who had an incarcerated paraesophageal hernia after a previous hiatal hernia repair died of sequelae of a small bowel obstruction after his Collis-Nissen operation. There were complications in 11 patients (19%): splenectomy necessitated by intraoperative trauma (two), postoperative hemorrhage (three), distal esophageal leak (two), abdominal wound dehiscence (one), small bowel obstruction (one), pulmonary embolus (one), and chylothorax (one). Average hospital stay was 13 days (range 7 to 68 days). One patient was lost to follow-up. Follow-upaverages 25 months (1 to 118 months) for the remaining 55 patients. Eighty-seven percent have no or minimal subjective reflux (Table I). The standard acid reflux test has objectively demonstrated good control of reflux in 92% of the patients postoperatively (Table II). However, in five patients with reflux symptoms and
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normal standard acid reflux test results, 24 hour monitoring of distal esophageal pH has demonstrated abnormal reflux (at 1 year in four patients and at 3 years in one patient). Preoperatively, eight patients had dysphagia necessitating dilation therapy. Five of these eight and an additional 20 patients required at least occasional dilations after their Collis-Nissen repair. At most recent follow-up, 67% had either an excellent or good result, requiring no treatment for either reflux or dysphagia. Eleven percent had a fair result, with dysphagia or reflux controlled by dilations or antacids. Of the 12 patients (22%) with poor results, 10 have had a subsequent operation. In one patient with severe dysphagia from an overly aggressive crural approximation, cutting a single suture gave an excellent result. The other nine patients underwent esophageal resection and their results are analyzed later in this report. Twenty-three patients (14 initially and nine after a failed Collis-Nissen operation) underwent esophageal resection as treatment of a failed antireflux operation. Four patients had a distal esophagectomy and shortsegment colon interposition, and 19 underwent a transhiatal esophagectomy without thoracotomy; 14 had esophageal replacement with stomach and five with colon. There were no operative deaths. Complications occurred in five patients (22%): cervical anastomotic leak, wound infection, small bowel obstruction, abdominal abscess, and aspiration in one each. Average hospital stay was 15 days (range 8 to 53 days). Follow-up averages 17 months (l to 84 months). Only one patient has symptomatic reflux necessitating treatment (Table I). Preoperatively, 12 of these patients had dysphagia necessitating dilation therapy. Postoperatively, three of these 12 and an additional 10 patients required at least occasional dilations after their esophagectomy. At latest follow-up, 65% have had either a good or excellent subjective response, having neither significant reflux symptoms nor dysphagia. One patient had dysphagia from a previous too tight Nissen fundoplication. The wrap was redone transabdominally with good results. In a final patient, a barium swallow 1 week after a Collis-Nissen procedure revealed an asymptomatic paraesophageal hernia caused by disruption of the crural repair. The hernia was reduced and the crural repair redoen with good results. These 87 patients underwent 99 operations to treat recurrent reflux or dysphagia after previous antireflux operations. Ten additional operations were required for complications. Overall operative mortality was 2% (two deaths). One patient has been lost to follow-up. Subjectively, 64 patients (76%) have had either good or excellent results (are either asymptomatic or have
minimal symptoms necessitating no treatment); 14 (17%), fair results (symptoms are controlled by medication or dilations); and six patients (7%), poor results (symptoms are uncontrolled). Among these patients, mild postoperative gas bloat syndrome has occurred once after a Coilis-Nissen repair, and mild dumping syndrome has occurred six times, three times after a Collis-Nissen repair and three times after esophagectomy. Discussion
Patients with failed antireflux operations constitute a major clinical challenge. The true magnitude of this problem is difficult to assess, because most patients who have antireflux procedures do not have adequate objective long-term follow-up. Current clinical reports,"? many based on subjective questioning of patients, indicate that after various "hiatal hernia" repairs, reflux is not controlled in 10% to 15% of the patients, and new symptoms not necessarily related to reflux develop in 10%to 25%. It is probable that poor operative results are even more common than these large reported series would suggest. The challenge is to identify those operative principles that are most critical to minimizing failure of the initial antireflux procedure. Regardless of the type of repair, the gastroesophageal junction must be identified accurately and mobilized completely so that reduction of a 3 to 5 em segment of distal esophagus belowthe diaphragmatic hiatus is achieved. Avoidance of tension on the repair is as critical at the diaphragmatic hiatus as it is in the repair on every abdominal wall hernia. To minimize postoperative dysphagia after a fundoplication, the wrap should be performed with a large dilator (54 Fr. or larger) across the esophagogastric junction. Approximation of the crura behind the esophagus ensures that the repair remains in the abdomen, but adequates bites of crural musculature and tendinous diaphragm must be taken if the crural reconstruction is to last. Acute postoperative events that stress the repair, such as violent involuntary "bucking" against the endotracheal tube by the semiconscious patient or gastric distention, must be avoided. The concept of "recurrence risk factors" I seems valid. Certain patients undergoing any antireflux operation have identifiable factors that predispose them to disruption of their repair and recurrent reflux. For example, 13% of our patients were marked obese and 17% had chronic obstructive pulmonary disease, both conditions that increase intra-abdominal pressure and tension on the diaphragmatic repair. In addition, the high incidence of inguinal (15%) and abdominal wall (13%) hernias in our patients suggests
Volume 92 Number 4 October 1986
that some recurrences may be related to intrinsic connective tissue weakness. We consider patients with failed antireflux operations to be at special risk for recurrence with subsequent standard repairs, because the periesophageal reaction that results from prior operation at the esophagogastric junction prevents the accurate placement of the fundoplication esophageal sutures into healthy esophageal muscle and submucosa. Placement of sutures into a distal esophagus that is shortened and inflamed by reflux esophagitis is suboptimal. As a rule, surgeons who prefer the Belsey, Nissen, or Hill repair for the initial treatment of gastroesophageal reflux, when confronted with a patient with recurrent reflux, simply advocate redoing "their" operation. It is usually, but by no means always, possible to redo a hiatal hernia operation at least once. Our current preference is to perform the combined esophaguslengthening Collis gastroplasty-Nissen fundoplication procedure, which ensures a tension-free repair and provides a healthy "neoesophagus" of resilient stomach rather than inflamed or scarred distal esophagus around which to perform the fundoplication. Certain details of redo antireflux operations warrant emphasis. A transthoracic approach is usually preferred for reoperative antireflux operations when another antireflux operation is likely. Adequate esophageal mobilization is not possible through the abdomen. If the problem is purely intra-abdominal (e.g., too tight a Nissen fundoplication), an abdominal approach to redo the wrap is advised. Placement of an intraesophageal dilator (40 Fr. or larger) within the esophagus facilitates its identification within mediastinal scar tissue. When mobilizing the stomach and esophagus, the surgeon should conscientiously "dissect wide," if necessary taking a thin layer of diaphragm or liver capsule to avoid devascularization of the gastric fundus. If after mobilization there is extensive disruption or devascularization of the esophagus or stomach, resection and visceral esophageal substitution is far safer than attempted local repair and repeat fundoplication. The colon is routinely prepared preoperatively in the event that it is needed for esophageal replacement. Whether it is preferable to resect only the distal esophagus and perform a short-segment left colon" or jejunal interposition" or to remove the entire thoracic esophagus and perform a cervical esophageal anastomosis to avoid the potential complications of an intrathoracic anastomostic leak'? II is still debatable. A contused cardia, which may follow takedown of a previous hiatal hernia repair, may be unsuitable for a repeat fundoplication, but does not necessarily preclude use of the stomach as an esophageal replacement and a cervical
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esophagogastric anastomosis. The devitalized portion of stomach may often be resected by stapling along the lesser curvature, providing a relatively healthy "tube" of greater curvature that readily reaches to the neck. A distal esophageal resection with intrathoracic esophagogastric anastomosis should virtually never be done in this setting because reflux esophagitis will develop after this procedure in at least 40% of patients. The proper selection of patients for esophageal resection requires judgment and experience. Those with nondilatable strictures or persistent fistulas at the esophagogastric junction after a prior antireflux operation usually require resection. However, rules of thumb regarding the need for esophageal resection based purely upon the number of previous unsuccessful antireflux operations are misleading. The type of previous procedure(s) has far more significance in influencing our decision for another attempt at an antireflux operation versus resection. For example, many patients with a history of previous unspecified "anatomic hiatal hernia" operations performed 15 to 30 years ago may have had little more than simple crural approximation, with minimal periesophageal or perihiatal reaction and a virtually "virgin" esophagogastric junction that is readily amenable to reconstruction. Alternatively, in the patient who has undergone a combined gastroplastyfundoplication operation, takedown of the repair for revision is often impossible, and resection is the only alternative. The decision for the type of redo operation, then, must be individualized and is based upon the surgeon's degree of experience, his preoperative assessment of the barium swallow, the results of endoscopy, and the findings at operation. Esophageal resection is indicated in patients with nondilatable strictures (including those that disrupt during attempted intraoperative dilation), those with chronic esophageal fistulas after prior repairs, and those in whom the fundus cannot be taken down after a previous fundoplication or is devascularized in the process of mobilization. We'? II currently advocate a transhiatal esophagectomy without thoracotomy and cervical esophagogastrostomy in patients in whom the need for esophageal resection is determined preoperatively. Symptoms of reflux esophagitis are eliminated when the esophagus is resected, and the patient with a cervical esophagogastric anastomosis has virtually no clinically significant reflux. Postoperative dysphagia from stenosis of the cervical esophagogastric anastomosis is minimized by construction of the anastomosis over a 46 Fr. or larger intraesophageal dilator. Other clinical reports" 12-16 of the surgical treatment of failed antireflux procedures describe good or excellent results in 66% to 90% of patients treated with a variety
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of hiatal hernia repairs and esophageal resection. Good or excellent results were obtained in 76% of our 87 patients, 12 (14%) of whom required a second operation. Our data and those of others indicate that the results of surgical treatment for failed antireflux operations are far from idea. There is a critical need to determine if the concept of "recurrence risk factors" is valid; that is, is it possible to identify preoperatively those patients who are more likely to have a poor result from a standard antireflux procedure? If so, are there specific operative techniques, such as the Collis gastroplasty, that can minimize the incidence of recurrence so that fewer patients must be considered for redo operations?
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for disruption and recurrence after Nissen fundoplication. Arch Surg 114:542-548, 1979 Leonardi HK, Crozier RE, Ellis FH: Reoperation for complications of the Nissen fundoplication. J THoRAe CARDIOVASC SURG 81:50-56, 1981 Maher JW, Hocking MP, Woodward ER: Reoperations for esophagitis following failed antireflux procedures. Ann Surg 201:723-727, 1985 Zueker K, Reskin GW, Saik RP: Recurrent hital hernia repair. Arch Surg 117:413-414, 1982 Little AG, Ferguson MK, Skinner DB: Reoperation for failed antireflux operations. J THORAC CARDIOVASC SURG 91:511-517,1986
Discussion
REFERENCES
DR. ROBERT D. HENDERSON
Orringer MB, Sloan HS: Collis-Belsey reconstruction of the esophagogastric junction. J THORAC CARDIOVASC SURG 71:295-303, 1976 Orringer MB, Sloan H: Combined Collis-Nissen reconstruction of the esophagogastric junction. Ann Thorac Surg 25:16-21,1978 Hiebert CA, O'Mara CS: The Belsey operation for hiatal hernia. A twenty year experience. Am J Surg 13:532-535, 1979 Negre JB: Post-fundoplication symptoms. Do they restrict the success of Nissen fundoplication? Ann Surg 198:698700, 1983 Negre JB, Marakula HT, Keyrilainen 0, Matisainen M: Nissen fundoplication. Results at 10 year follow-up. Am 1 Surg 146:635-637, 1983 Orringer MB, Skinner DB, Belsey RHR: Long-term results of the Mark IV operation for hiatal hernia and analysis of recurrences and their treatment. J THORAC CARDIOVASC SURG 63:25-31, 1972 Polk HC Jr: Fundoplication for reflux esophagitis. Misadventures with the operation of choice. Ann Surg 182:645652, 1976 Belsey RHR: Reconstruction of the esophagus with left colon. J THORAC CARDIOVASC SURG 49:33-55, 1965 Polk HC: Jejunal interposition for reflux esophagitis and esophageal stricture unresponsive to valvuloplasty. Would J Surg 4:731-736, 1980 Orringer MB: Technical aids in performing transhiatal esophagectomy without thoracotomy. Ann Thorac Surg 38: 128-132, 1984 Orringer MB: Transhiatal esophagectomy for benign disease. J THORAC CARDIOVASC SURG 90:649-655, 1985 Hill LD, Riivo I, Stevenson JK, Pearson JM: Reoperation
Toronto. Ontario. Canada
I have had a particular interest in revision esophageal surgery that can be illustrated by examining two groups of patients. The first study comprises 335 consecutive patients treated by total fundoplication gastroplasty (TFG). The second group of 190 are patients with previous esophageal operations who are treated by thoracoabdominal TFG with pyloromyotomy. Both groups have been followed up for a minimum of 5 years. In the first group 93.1% are eating normally, 3.9% have moderate residual symptoms, and 3% have persistence or recurrence of major symptoms. According to the same classification, 86.8% of patients requiring revision TFG asymptomatic, 7.9% have minor residual symptoms, 4.7% major symptoms, and one patient (0.5) died. Further analysis shows that in patients with both patients gastric and esophageal operations there is a slight further deterioration of the results achieved. These results demonstrate that, despite the increased technical difficulty of redo operations, satisfactory results can still be achieved. DR. STIRLING (Closing) We appreciate Dr. Henderson's comments and acknowledge his extensive experience with this problem. His results suggest that previous gastric surgery should be added to the list of recurrence risk factors. In closing, we would like to emphasize our dissatisfaction with the results of reoperative antireflux operations. A 24% failure rate for benign disease is clearly unsatisfactory. These results will be improved only by identifying patients predisposed to recurrence and by modifying surgical techniques to minimize subsequent failure after standard repairs.