1. Re-operative anti-reflux surgery: When and How? Lee L. Swanstrom, MD Division of Minimally Invasive Surgery Legacy Health System Dept of Surgery, OR Health Sciences University

2. Results: Laparoscopic Nissen - 10/91 to 9/99 644 primary Nissens for GERD age = 52 (14 - 87) 64% males OR time 136 min (52 - 235) LOS 1.6 days (0 - 17) Mortality = 0 Complications 11% 599 good to excellent results (93%) early failure = 12 (2%) reoperation = 32 (5%) on medication = 103 (16%) 241 with objective f/u: –38 (16%) had evidence of continued reflux Swanstrom, Jobe; Surgical Endosc; 1999

3. What is a failed fundoplication? Continued use of peptic medication? Heartburn/Reflux? Side effects related to surgery? –Dysphagia –Gasbloat –Nausea/diarrhea Objective test results? –24 hr pH –EGD/UGI –manometry

4. Failure Residual or recurrent symptoms Wrap herniation or disruption Abnormal 24 hr. pH Non-dilatable dysphagia (worse than before)

5. Not… Side effects Use of medications Symptoms alone

6. Do symptoms mean there is reflux? –2/3 of patients c/o post op GERD sx have normal 24 hr pH –9% of patients with no symptoms have a pos. 24 hr pH. Khajanchee YS, “Postoperative Symptoms and failure following antireflux surgery” Arch Surg, 2002. 137(9):1008-14.

7. Risk of recurrence Type V (recurrent, postoperative) Type IV (giant, multivisceral) Type III (combined) Type I (sliding) Type II (rolling) –Fundus herniated into mediastinum –GE junction in normal position Low High

8. Modes of Failure After ARS Modes of Failure After ARS h Gastric retraction without adequate esophageal length GEJ retracted below diaphragm under tension GEJ retracted below diaphragm under tension Malpositioning of the fundoplication

9. Why do fundoplications fail?

10. Failed fundoplication Wrong surgeon Wrong surgery Wrong patient Technical error

11. “Patients with substantial psychological overlay cannot be expected to do as well with standard therapy…” Avoid the crazed, bulemic, voluntary wretching, aerophagic patients…

12. Mechanical problems: failures are due to: –wrap herniation* –wrap disruption* –malpositioned wrap –reflux through intact wrap *mostly as a result of a repair under tension

13. Reasons for failure Repairs under tension! Torsion = divide the short gastricsTorsion = divide the short gastrics Wrap = loose fundoplicationWrap = loose fundoplication Axial = beware the short esophagus!Axial = beware the short esophagus!

14. Who should be considered for another antireflux surgery? Patients with daily symptoms (heartburn/dysphagia) requiring chronic medical treatment patients who have complications from GERD coming back Patients with objective confirmation of failure Patients with a defined mechanical or physiologic reason for failure

15. An extensive preoperative evaluation is critical for the difficult patient Complete medical evaluation Comprehensive esophageal physiology testing –UGI –endoscopy –motility testing –24 hr pH test –gastric emptying study Don’t hesitate to say “No”

17. Motility for: esophageal length Esophageal function LES function pH for: Reflux? Correlation without Symptom correlation

19. Technique

20. setup

21. adhesiolysis

23. L crural exposure

24. R crus

25. Retro-gastric adhesions

26. Slipped Nissen

27. Type II dissection

28. Transhiatal dissection will achieve esophageal mobilization in the majority of cases

29. The Short Esophagus Incidence –1% - 3% Risk factors –long standing, severe disease –stricture –GEJ more than 5cm above the hiatus –Barrett’s

30. Shortened esophagus on preop imaging Laparoscopic approach Standard dissection to achieve 2 cm of intraabdominal length Extensive Type II Fundoplication dissection (Nissen) No Almost Yes Collis gastroplasty Hill procedure noyes

31. Check for short esophagus If short, do a lengthening procedure

32. Thoracoscopic/Laparoscopic Approach

37. Disassemble wrap

39. Completely undone

40. Appropriate wrap placement

41. Endoscopic adjustment

42. Original fixation

43. Complete fundoplication

44. Reoperative laparoscopic antireflux surgery results

45. Progressive failure * ** *** * 209 patients ** 82 patients *** 21 patients

46. Risk of failure with laparoscopic Nissen

47. Real life 46 yo male with 20+ years of reflux Normal body motility, LES = 7.5mm/Hg Grade 2 esophagitis, 3 cm Barretts 1996 laparoscopic Nissen –Asymptomatic post op X 4 years

48. 2002 complains of persistent dysphagia and chest pain No response to dilatation Normal 24 hr pH LES pressure 30.5 Decreased esophageal body motility (IEM) Delayed gastric emptying ?

49. Conclusions: Fundoplications fail for a multitude of reasons – most avoidable but not all Thorough preop evaluation is critical Taylor the reoperative intervention Perform the surgery well –Close the hiatus –Avoid tension –Watch for the short esophagus –mesh

50. Laparoscopic reoperative antireflux surgery: The stakes are high –Controversy over efficacy Damage credibility –Higher complication rates –Opportunity to make things worse Medical legal risk

51. Problem prevention: Careful attention to patient symptoms and complaints A thorough and complete evaluation –EGD –Motility –24 hr pH –Gastric emptying –Bernstein –Bilitek –Impedance testing No hesitation to say “no”! On all patients

52. Avoid wrap tightness! Short, floppy fundoplication Use a large dilator

54. Avoid axial tension! Recognize and treat (or avoid) the “short esophagus”

55. Reoperative ARS Know ahead of time what went wrong Tell the patient the bad news Prep for a Collis Have a flexible endoscope in the room sharp, precise dissection Completely take down the old repair Check for leaks Be patient

56. Thank you