1
|
Siemssen B, Hentschel F, Ibach MJ. Long-term results after laparoscopic revision fundoplication: a retrospective, single-center analysis in 194 patients with recurrent hiatal hernia. Esophagus 2024; 21:390-396. [PMID: 38709415 DOI: 10.1007/s10388-024-01060-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/11/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND After laparoscopic fundoplication, 10-20% of patients experience symptom recurrence-often due to resurgence of the hiatal hernia. The standard surgical treatment for such cases remains laparoscopic revision fundoplication. However, there is little data on the time frame and anatomic patterns of failed fundoplications. Additionally, few large studies exist on the long-term efficacy and safety of laparoscopic revision fundoplication. METHODS In a single-center, retrospective analysis of 194 consecutive revision fundoplications for recurrent reflux disease due to hiatal hernia, we collected data on time to failure and patterns of failure of the primary operation, as well as on the efficacy and safety of the revision. RESULTS The median time to failure of the primary fundoplication was 3 years. Most hiatal defects were smaller than 5 cm and located anteriorly or concentric around the esophagus. Laparoscopic redo fundoplication was technically successful in all cases. The short-term complication rate was 9%, mainly dysphagia requiring endoscopic intervention. At a mean follow-up of 4.7 years, 77% of patients were symptom-free, 14% required daily PPI, and 9% underwent secondary revision. Cumulative failure rates were 9%, 23%, and 31% at 1, 5, and 10 years. CONCLUSION The majority of failed fundoplications occur within 3 years of primary surgery, with most patients exhibiting anterior or concentric defects. For these patients, laparoscopic revision fundoplication is a safe procedure with a low rate of short-term complications and satisfactory long-term results.
Collapse
Affiliation(s)
- Björn Siemssen
- Department of Surgery, MIC Klinik, Kurstr. 11, 14129, Berlin, Germany.
| | - Florian Hentschel
- Medizinische Hochschule Brandenburg, Zentrum für Innere Medizin Universitätsklinikum Brandenburg an der Havel, Brandenburg, Germany
| | | |
Collapse
|
2
|
Hanna NM, Kumar SS, Collings AT, Pandya YK, Kurtz J, Kooragayala K, Barber MW, Paranyak M, Kurian M, Chiu J, Abou-Setta A, Ansari MT, Slater BJ, Kohn GP, Daly S. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc 2024; 38:2917-2938. [PMID: 38630179 DOI: 10.1007/s00464-024-10816-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia. METHODS We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively. RESULTS We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery. CONCLUSIONS The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
Collapse
Affiliation(s)
- Nader M Hanna
- Department of Surgery, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Yagnik K Pandya
- Department of Surgery, MetroWest Medical Center, Framingham, MA, USA
| | - James Kurtz
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | | | - Meghan W Barber
- Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA
| | - Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Marina Kurian
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | | | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | | | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, Australia
- Melbourne Upper GI Surgical Group, Melbourne, Australia
| | - Shaun Daly
- Department of Surgery, University of California Irvine, Irvine, USA
| |
Collapse
|
3
|
Delgado-Miguel C, Camps JI. Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study. Int J Med Robot 2023; 19:e2541. [PMID: 37317669 DOI: 10.1002/rcs.2541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/21/2023] [Accepted: 06/02/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Robotic-assisted redo fundoplication has some advantages compared to the laparoscopic approach in adults, although to date there are no studies in children. METHODS A retrospective case-control study was performed among consecutive children who underwent redo antireflux surgery between 2004 and 2020, divided into two groups: LAF group (laparoscopic redo-fundoplication) and RAF group (robotic-assisted redo-fundoplication). Demographics, clinical, intraoperative, postoperative and economic data were compared. RESULTS A total of 24 patients were included (10 LAF group; 14 RAF group) without demographic or clinical differences. The RAF group presented lower intraoperative blood loss (52 ± 19 vs. 145 ± 69 mL; p < 0.021), shorter surgery time (135 ± 39 vs. 179 ± 68 min; p = 0.009) and shorter length of hospital stay (median 3 days [2-4] vs. 5 days [3-7]; p = 0.002). The RAF group presented a higher rate of symptom improvement (85.7% vs. 60%; p = 0.192) and lower overall associated economic costs (25 800$ vs. 45 500$; p = 0.012). CONCLUSION Robotic-assisted redo antireflux surgery may offer several benefits over the laparoscopic approach. Prospective studies are still needed.
Collapse
Affiliation(s)
- Carlos Delgado-Miguel
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, South Carolina, USA
- Institute for Health Research IdiPAZ, La Paz University Hospital, Madrid, Spain
| | - Juan I Camps
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, South Carolina, USA
| |
Collapse
|
4
|
S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
|
5
|
Castillo-Larios R, Gunturu NS, Cornejo J, Trooboff SW, Giri AR, Bowers SP, Elli EF. Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-reflux surgery: which is better? Surg Endosc 2023:10.1007/s00464-023-10074-1. [PMID: 37130984 DOI: 10.1007/s00464-023-10074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/26/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Different techniques have been proposed for reoperation after failed anti-reflux surgery. However, there is no consensus on which should be preferred. We aim to report and compare the outcomes of different revisional techniques for failed anti-reflux surgery. METHODS We performed a retrospective analysis of patients who underwent redo fundoplication (RF) or Roux-en-Y gastric bypass (RYGB) conversion after a failed fundoplication at our institution between 2016 and 2021. The primary outcome was long-term presence of reflux or dysphagia following revisional surgery. Secondary outcomes included 30-day perioperative complications as well as long-term use of anti-reflux medication and radiographic recurrence of hiatal hernia (HH). RESULTS A total of 165 (median age 63 years, 73.9% female) patients were included. RF was performed in 120 (73 Toupet and 47 Nissen), RYGB in 38, and 7 patients had fundoplication takedown alone. The RYGB group had a significantly higher BMI, and more prior revisional surgeries compared to the other groups. Median operative time and length of stay were longer for RYGB. Twenty (12.1%) patients experienced postoperative complications, with the highest incidence in the RYGB group. Reflux and dysphagia improved significantly for the whole cohort, with the greatest improvement noted with reflux in the RYGB group (89.5% with preoperative reflux vs. 10.5% with postoperative reflux, p = < .001). On multivariable regression we found that prior re-operative surgery was associated with persistent reflux and dysphagia, whereas RYGB conversion was protective against reflux. CONCLUSION Conversion to RYGB may offer superior resolution of reflux than RF, especially for obese patients.
Collapse
Affiliation(s)
- Rocio Castillo-Larios
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Naga Swati Gunturu
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Jorge Cornejo
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Spencer W Trooboff
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | | | - Steven P Bowers
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Enrique F Elli
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
| |
Collapse
|
6
|
Robotic revision surgery after failed Nissen anti-reflux surgery: a single center experience and a literature review. J Robot Surg 2023:10.1007/s11701-023-01546-6. [PMID: 36862348 PMCID: PMC9979125 DOI: 10.1007/s11701-023-01546-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review. METHODS We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery. RESULTS Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43-71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110-225) and the mean hospital stay was 3.2 days (range, 2-7). At a mean follow-up of 78 months (range, 18-192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien-Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage. CONCLUSION Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty.
Collapse
|
7
|
Ghosh G, Choi AY, Dbouk M, Greenberg J, Zarnegar R, Murray M, Janu P, Thosani N, Dayyeh BKA, Diehl D, Nguyen NT, Chang KJ, Canto MI, Sharaiha R. Transoral incisionless fundoplication for recurrent symptoms after laparoscopic fundoplication. Surg Endosc 2023; 37:3701-3709. [PMID: 36650353 DOI: 10.1007/s00464-023-09880-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/08/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Revision of a failed laparoscopic fundoplication carries higher risk of complication and lower chance of success compared to the original surgery. Transoral incisionless fundoplication (TIF) may be an endoscopic alternative for select GERD patients without need of a moderate/large hiatal hernia repair. The aim of this study was to assess feasibility, efficacy, and safety of TIF 2.0 after failed laparoscopic Nissen or Toupet fundoplication (TIFFF). METHODS This is a multicenter retrospective cohort study of patients who underwent TIFFF between September 2017 and December 2020 using TIF 2.0 technique (EsophyX Z/Z+) performed by gastroenterologists and surgeons. Patients were included if they had (1) recurrent GERD symptoms, (2) pathologic reflux based upon pH testing or Grade C/D esophagitis or Barrett's esophagus, and (3) hiatal hernia ≤ 2 cm. The primary outcome was improvement in GERD Health-Related Quality of Life (GERD-HRQL) post-TIFFF. The TIFFF cohort was also compared to a similar surgical re-operative cohort using propensity score matching. RESULTS Twenty patients underwent TIFFF (median 4.1 years after prior fundoplication) and mean GERD-HRQL score improved from 24.3 ± 22.9 to 14.75 ± 21.6 (p = 0.014); mean Reflux Severity Index (RSI) score improved from 14.1 ± 14.6 to 9.1 ± 8.0 (p = 0.046) with 8/10 (80%) of patients with normal RSI (< 13) post-TIF. Esophagitis healed in 78% of patients. PPI use decreased from 85 to 55% with 8/20 (45%) patients off of PPI. Importantly, mean acid exposure time decreased from 12% ± 17.8 to 0.8% ± 1.1 (p = 0.028) with 9/9 (100%) of patients with normalized pH post-TIF. There were no statistically significant differences in clinical efficacy outcomes between TIFFF and surgical revision, but TIFFF had significantly fewer late adverse events. CONCLUSION Endoscopic rescue with TIF is a safe and efficacious alternative to redo laparoscopic surgery in symptomatic patients with appropriate anatomy and objective evidence of persistent or recurrent reflux.
Collapse
Affiliation(s)
- Gaurav Ghosh
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1283 York Ave, 9th Floor, New York, NY, 10065, USA.
| | - Alyssa Y Choi
- HH Chao Comprehensive Digestive Disease Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jacques Greenberg
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | | | - Peter Janu
- Fox Valley Surgical Associates, Affinity Health Systems, Appleton, WI, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, Danville, PA, USA
| | - Ninh T Nguyen
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Kenneth J Chang
- HH Chao Comprehensive Digestive Disease Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital/Weill Cornell Medicine, 1283 York Ave, 9th Floor, New York, NY, 10065, USA
| | | |
Collapse
|
8
|
Lin J, Melkonian V, Okeke RI, Platz J, Naunheim KS. A Rare Occurrence of Rotational Retro-Esophageal Gastric Body Herniation Through a Nissen Fundoplication. Cureus 2022; 14:e27732. [PMID: 36106292 PMCID: PMC9444046 DOI: 10.7759/cureus.27732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 12/03/2022] Open
Abstract
Anti-reflux procedures have become a mainstay in managing gastroesophageal reflux disease (GERD) and hiatal hernia. Unfortunately, post-operative events such as breakdown of the wrap, downward slippage, or transdiaphragmatic herniation of an intact wrap cause these procedures to fail and create complications such as recurrent hiatal hernia and reflux dysphagia, regurgitation, and obstruction requiring revision surgery. We discuss a case of a rotational retro-esophageal herniation of the gastric body through a Nissen fundoplication presenting as obstruction, dysphagia, and regurgitation, highlighting the peculiar nature of this presentation and the ease of misdiagnosis given its rarity.
Collapse
|
9
|
Braghetto I, Korn O, Figueroa-Giralt M, Valenzuela C, Burgos AM, Mandiola C, Sotomayor C, Villa E. LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1678. [PMID: 36102488 PMCID: PMC9462863 DOI: 10.1590/0102-672020220002e1678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.
Collapse
|
10
|
Yano F, Tsuboi K, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Mitsumori N, Ikegami T. Treatment strategy for laparoscopic hiatal hernia repair. Asian J Endosc Surg 2021; 14:684-691. [PMID: 33472278 DOI: 10.1111/ases.12918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 01/06/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION According to the anatomy-function-pathology classification, the recurrence rates of A2 and A3 hiatal hernia (HH) after laparoscopic fundoplication are higher than the rate of A1 HH. Therefore, we introduced mesh reinforcement for A2 and A3 cases. In addition, gastropexy was added to A3 cases. We present the strategy for HH repair. METHODS In all, 537 patients (mean age 55.4 ± 16.7 years, 219 women) who underwent primary laparoscopic fundoplication for HH from January 1995 to October 2019 were included. They were divided into three groups by A factor (A1:A2:A3 = 296:156:85). Their clinical data were collected in a prospective fashion and retrospectively reviewed. RESULTS The median age (years) of the patients in each group was A1:A2:A3 = 46:63:74 years, and age was directly proportional to the size of HH (P < 0.0001). The proportion of females was significantly higher in A3 than in other classes (P < 0.0001). Preoperative reflux esophagitis was severe in A2 (P < 0.0001) and operation time (min) was directly proportional to HH size (A1:A2:A3 = 135:167:193, P < 0.0001). The recurrence rate of conventional laparoscopic fundoplication was 15% (46/304), and it was higher for A2 and A3 than for A1 (P = 0.027). However, with reinforcement of the hiatus using a mesh and gastropexy, the recurrence rates decreased. CONCLUSION Combining mesh reinforcement and gastropexy may reduce the recurrence rate of para- and mixed-type HH.
Collapse
Affiliation(s)
- Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuto Tsuboi
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se R Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Norio Mitsumori
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
11
|
Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis. Ann Surg 2021; 274:78-85. [PMID: 33214483 DOI: 10.1097/sla.0000000000004639] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF). SUMMARY OF BACKGROUND DATA Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair. METHODS A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%). CONCLUSIONS LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.
Collapse
|
12
|
Low-pressure Pneumoperitoneum With Abdominal Wall Lifting Versus Standard Pressure Pneumoperitoneum in Laparoscopic Fundoplication for Gastroesophageal Reflux Disease: A Propensity Score-matched Analysis. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2021; 32:46-53. [PMID: 34369478 DOI: 10.1097/sle.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/26/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare the treatment results of low-pressure pneumoperitoneum with abdominal wall lifting (AWL+LP, 6 mm Hg) versus standard pressure pneumoperitoneum (SP, 12 mm Hg) during laparoscopic fundoplication for gastroesophageal reflux disease (GERD), using propensity score matching (PSM). MATERIALS AND METHODS A retrospective analysis was made of 362 patients, 123 in the AWL+LP group and 239 in the SP group, who underwent laparoscopic fundoplication for GERD from January 2010 to December 2017. Perioperative and prognostic outcomes were compared after PSM with 1:1 match. RESULTS After PSM, 107 matched pairs were obtained. Compared with the SP group at 30 and 60 minutes after pneumoperitoneal initiation, the AWL+LP group showed significantly lower end-tidal carbon dioxide value (P<0.001, <0.001, respectively), lower partial pressure of carbon dioxide value (P<0.001, 0.016, respectively) and significantly higher pH value (P<0.001, <0.001, respectively). However, postoperative shoulder pain, abdominal pain, and arrhythmia in the AWL+LP group were less than those in SP group (P=0.01, 0.017, 0.005, respectively). There was no significant difference in operative time (106.54±27.80 vs. 107.38±24.78 min), blood loss [15 mL (interquartile range: 12.5 to 20 mL) vs.15 mL (interquartile range: 10 to 20 mL)], length of stay (4 vs. 4 d), the wound ecchymosis [2 (1.87%) vs. 3 (2.80%)] and rates of recurrence [8 (7.48%) vs. 5 (4.67%)] between AWL+LP group and SP group. CONCLUSION AWL+LP resulted in comparable perioperative and prognostic outcomes with less impact on changes in cardiorespiratory function compared with SP approaches of laparoscopic fundoplication for GERD.
Collapse
|
13
|
Characteristics and outcomes of patients undergoing paraesophageal hernia repair with selective use of biologic mesh. Surg Endosc 2021; 36:1627-1632. [PMID: 34076763 DOI: 10.1007/s00464-021-08399-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The use of biologic mesh in paraesophageal hernia repair (PEHR) has been associated with decreased short-term recurrence but no statistically significant difference in long-term recurrence. Because of this, we transitioned from routine to selective use of mesh for PEHR. The aim of this study was to examine our indications for selective mesh use and to evaluate patient outcomes in this population. METHODS We queried a prospectively maintained database for patients who underwent laparoscopic PEHR with biologic mesh from October 2015 to October 2018, then performed a retrospective chart review. The decision to use mesh was made intraoperatively by the surgeon. Recurrence was defined as the presence of > 2 cm intrathoracic stomach on postoperative upper gastrointestinal (UGI) series. RESULTS Mesh was used in 61/169 (36%) of first-time PEHRs, and in 47/82 (57%) of redo PEHRs. Among first-time PEHRs, the indications for mesh included hiatal tension (85%), poor crural tissue quality (11%), or both (5%). Radiographic recurrence occurred in 15% of first-time patients (symptomatic N = 2, asymptomatic N = 3). There were no reoperations for recurrence. Among redo PEHRs, the indication for mesh was most commonly the redo nature of the repair itself (55%), but also hiatal tension (51%), poor crural tissue quality (13%), or both (4%). Radiographic recurrence occurred in 21% of patients (symptomatic N = 4, asymptomatic N = 1). There was 1 reoperation for recurrence in the redo-repair group. CONCLUSIONS We selectively use biologic mesh in a third of our first-time repair patients and in over half of our redo-repair patients when there is a perceived high risk of recurrence based on hiatal tension, poor tissue quality, or prior recurrence. Despite the high risk for radiologic recurrence, there was only 1 reoperation for recurrence in the entire cohort.
Collapse
|
14
|
DeSantis AJ, Barry T, Saad AR, DuCoin C, Jacobs JW, Richter JE, Velanovich V. Etiology and Reoperative Management of Postoperative Recalcitrant Dysphagia after Nissen Fundoplication: Skipping the Ounce of Prevention Resulting in a Pound of Cure. J Gastrointest Surg 2021; 25:1559-1561. [PMID: 33169319 DOI: 10.1007/s11605-020-04856-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/31/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Anthony J DeSantis
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Tara Barry
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA
| | - Adham R Saad
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Christopher DuCoin
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - John W Jacobs
- Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.,Division of Gastroenterology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA. .,Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| |
Collapse
|
15
|
Rausa E, Manfredi R, Kelly ME, Bianco F, Aiolfi A, Bonitta G, Zappa MA, Lucianetti A. Prosthetic Reinforcement in Hiatal Hernia Repair, Does Mesh Material Matter? A Systematic Review and Network Meta-Analysis. J Laparoendosc Adv Surg Tech A 2020; 31:1118-1123. [PMID: 33332239 DOI: 10.1089/lap.2020.0752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Hiatal hernia repair (HHR) is a complex surgical procedure and its management is not standardized. Several meta-analyses have compared cruroplasty with hiatus reinforcement with mesh, and crura augmentation appears to have better outcomes. However, heterogeneity in type of mesh and placement techniques has differed significantly. Materials and Methods: A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out throughout Pubmed, CENTRAL, and Web of Science, of articles analyzing HHR with cruroplasty, nonabsorbable mesh (NAM), and absorbable mesh (AM) reinforcement. Results: Seventeen articles based on 1857 patients were enrolled in this article. The point estimation showed that when compared against the control group (NAM), the HH recurrence risk in AM and cruroplasty group was higher (relative ratio [RR] 2.3; CrI 0.8-6.3, RR 3.6; CrI 2.0-8.3, respectively). Postoperative complication rates were alike in all groups. The prevalence of mesh erosion after HHR is low. Conclusions: This network meta-analysis showed that prosthetic reinforcement significantly reduced HH recurrence when compared with cruroplasty alone. However, there is not enough evidence to compare different mesh compositions.
Collapse
Affiliation(s)
- Emanuele Rausa
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Michael E Kelly
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Federica Bianco
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alberto Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | | | - Marco A Zappa
- Division of General Surgery, Fatebenefratelli Hospital, Milan, Italy
| | | |
Collapse
|
16
|
Huettl F, Lang H, Paschold M, Bartsch F, Hiller S, Hensel B, Corvinus F, Grimminger PP, Kneist W, Huber T. Quality-based assessment of camera navigation skills for laparoscopic fundoplication. Dis Esophagus 2020; 33:5849144. [PMID: 32476009 DOI: 10.1093/dote/doaa042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/05/2020] [Accepted: 04/27/2020] [Indexed: 12/11/2022]
Abstract
Laparoscopic fundoplication is considered the gold standard surgical procedure for the treatment of symptomatic hiatus hernia. Studies on surgical performance in minimally invasive hiatus hernia repair have neglected the role of the camera assistant so far. The current study was designed to assess the applicability of the structured assessment of laparoscopic assistance skills (SALAS) score to laparoscopic fundoplication as an advanced and commonly performed laparoscopic upper GI procedure. Randomly selected laparoscopic fundoplications (n = 20) at a single institute were evaluated. Four trained reviewers independently assigned SALAS scoring based on synchronized video and voice recordings. The SALAS score (5-25 points) consists of five key aspects of laparoscopic camera navigation as previously described. Experience in camera assistance was defined as at least 100 assistances in complex laparoscopic procedures. Nine different surgical teams, consisting of five surgical residents, three fellows, and two attending physicians, were included. Experienced and inexperienced camera assistants were equally distributed (10/10). Construct validity was proven with a significant discrimination between experienced and inexperienced camera assistants for all reviewers (P < 0.05). The intraclass correlation coefficient of 0.897 demonstrates the score's low interrater variability. The total operation time decreases with increasing SALAS score, not reaching statistical significance. The applied SALAS score proves effective by discriminating between experienced and inexperienced camera assistants in an upper GI surgical procedure. This study demonstrates the applicability of the SALAS score to a more advanced laparoscopic procedure such as fundoplication enabling future investigations on the influence of camera navigation on surgical performance and operative outcome.
Collapse
Affiliation(s)
- Florentine Huettl
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Markus Paschold
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Fabian Bartsch
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Sebastian Hiller
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Benjamin Hensel
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Florian Corvinus
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Werner Kneist
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany.,Department of General and Visceral Surgery, St. Georg Hospital, Eisenach, Germany
| | - Tobias Huber
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| |
Collapse
|
17
|
Nguyen R, Dunn CP, Putnam L, Won P, Patel T, Brito S, Bildzukewicz NA, Lipham JC. Less is more: cruroplasty alone is sufficient for revisional hiatal hernia surgery. Surg Endosc 2020; 35:4661-4666. [PMID: 32839876 DOI: 10.1007/s00464-020-07897-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/05/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Recurrence of hiatal hernia after anti-reflux surgery is common, with past studies reporting recurrence rates of 10-15%. Most patients experience relief from GERD symptoms following initial repair; however, those suffering from recurrence can have symptoms severe enough to warrant another operation. Although the standard of care is to revise the fundoplication or convert to magnetic sphincter augmentation (MSA) in addition to redo cruroplasty, it stands to reason that with an intact fundoplication, a repeat cruroplasty is all that is necessary to alleviate the patients' symptoms. In other words, only fix that which is broken. METHODS A retrospective review of patients with symptomatic hiatal hernia recurrence who underwent reoperation between January 2011 and September 2018 was conducted. Patients who received revisional cruroplasty alone were compared with cruroplasty plus some other revision (fundoplication revision, or takedown and MSA placement). Demographics, operative details, and postoperative outcomes were collected. RESULTS There were 73 patients identified. Median time to recurrence after the first procedure was 3.7 (1.9-8.2) years. Thirty-two percent of the patients had GERD symptoms for more than 10 years. Twenty-six patients underwent cruroplasty only. Forty-seven patients underwent cruroplasty plus fundoplication revision. There were no significant differences in operative times (2.4 h cruroplasty alone, 2.8 h full revision, p = 0.75) or postoperative complications between the two groups. Patients had a mean follow-up time of 1.64 years. Of the 73 patients, 8 had subsequent hiatal hernia recurrence. The recurrence rate for patients with cruroplasty alone was 11%, and the recurrence rate for the full revision group was 12% (p = 1.00). CONCLUSION Leaving an intact fundoplication alone at the time of revisional surgery did not adversely affect surgical outcomes. This data suggests a role for hernia-only repair for recurrent hiatal hernias.
Collapse
Affiliation(s)
- Robert Nguyen
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA
| | - Colin P Dunn
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA.,Hoag Memorial Hospital Presbyterian Digestive Health Institute, Newport Beach, CA, USA
| | - Luke Putnam
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA.,Hoag Memorial Hospital Presbyterian Digestive Health Institute, Newport Beach, CA, USA
| | - Paul Won
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA
| | - Tanu Patel
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA
| | - Stephanie Brito
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA
| | - Nikolai A Bildzukewicz
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA.,Hoag Memorial Hospital Presbyterian Digestive Health Institute, Newport Beach, CA, USA
| | - John C Lipham
- The Division of Upper GI and General Surgery, University of Southern California, Los Angeles, CA, USA. .,Hoag Memorial Hospital Presbyterian Digestive Health Institute, Newport Beach, CA, USA. .,Keck Medical Center of USC, University of Southern California, 1510 San Pablo St #514, Los Angeles, CA, 90033, USA.
| |
Collapse
|
18
|
Shao JM, Elhage SA, Prasad T, Gersin K, Augenstein VA, Colavita PD, Heniford BT. Best reoperative strategy for failed fundoplication: redo fundoplication or conversion to Roux-en-Y gastric diversion? Surg Endosc 2020; 35:3865-3873. [PMID: 32676728 DOI: 10.1007/s00464-020-07800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Failed fundoplication is a difficult reoperative challenge, with limited evidence differentiating outcomes of a redo fundoplication versus conversion to Roux-en-Y anatomy with a gastric diversion (RYGD). The aim of this study was to determine the impact of these reoperative strategies on symptom resolution. METHODS A retrospective single institution study of patients with failed fundoplications undergoing conversion to RYGD or redo fundoplication between 2006 and 2019 was conducted. Patient characteristics, preoperative evaluation, operative findings, and postoperative outcomes were recorded and analyzed. RESULTS 180 patients with symptomatic, failed fundoplications were identified: 101 patients (56.1%) underwent conversion to RYGD, and 79 patients (43.9%) underwent redo fundoplication. Body mass index (BMI) was significantly higher for the patients undergoing RYGD with mean BMI of 34.3 ± 6.9 vs 27.7 ± 3.9 kg/m2 (p < 0.001). Patients undergoing conversion to RYGD were also more comorbid than their counterparts, with higher rates of obstructive sleep apnea (17.8% vs 5.1%, p = 0.01), but similar rates of hypertension (54.5% vs 44.3%, p = 0.18, asthma/COPD (25.7% vs 16.5%, p = 0.13), diabetes (10.9% vs 10.1%, p = 0.87), and hyperlipidemia (29.7% vs 36.7%, p = 0.32). Mean operative times were significantly higher for the RYGD (359.6 ± 90.4 vs 238.8 ± 75.6 min, p < 0.0001), as was mean estimated blood loss (168.8 ± 207.5 vs 81.0 ± 145.4, p < 0.0001). Conversion rates from minimally invasive to open were similar (10.9% vs 11.4%, p = 0.92). The incidence of recurrent reflux symptoms was not significantly different (p = 0.46) between RYGD (16.8%) and redo fundoplication (12.8%), at an average follow-up of 50.6 ± 140.7 vs 34.7 ± 39.2 months, (p = 0.03). For the RYGD cohort, patients also had resolution of other comorbidities including obesity 35.6%, OSA 16.7%, hyperlipidemia 10.0%, hypertension 9.1%, and diabetes 9.1%. On average, patients decreased their BMI by 6.8 ± 5.5 kg/m2 and lost 69.6% of their excess body weight. Mean length of stay was higher in patients undergoing RYGD (5.3 ± 7.3 vs 3.0 ± 1.9 days, p = 0.01). Thirty-day readmission rates were similar (9.9% vs 3.8%, p = 0.12). The reoperation rate was higher in the RYGD cohort (17.8% vs 2.5%, p = 0.001). CONCLUSIONS RYBG and redo fundoplication are equivalent in terms of resolution of reflux. RYGD resulted in significant loss of excess body weight.
Collapse
Affiliation(s)
- Jenny M Shao
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sharbel A Elhage
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Tanu Prasad
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Keith Gersin
- Atrium Health Weight Management, Department of Surgery, Carolinas Medical Center, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA.
| |
Collapse
|
19
|
Giovannetti A, Craigg D, Castro M, Ross S, Sucandy I, Rosemurgy A. Laparoendoscopic Single-Site (LESS) versus Robotic “Redo” Hiatal Hernia Repair with Fundoplication: Which Approach is Better? Am Surg 2019. [DOI: 10.1177/000313481908500939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Only a small percentage of patients fail laparoscopic fundoplications undertaken for gastroesophageal reflux disease. But because many laparoscopic fundoplications have been undertaken, surgeons frequently encounter patients in need of “redo” operations. This study was undertaken to evaluate the robotic approach versus laparoendoscopic single-site (LESS) approach for redo fundoplications. With an Institutional Review Board approval, 64 patients undergoing LESS (n = 32) or robotic (n = 32) redo antireflux operations were prospectively followed up. Data are presented as median (mean + SD). For LESS versus robotic redo operations, the operative duration was 145 (143 ± 33.5) versus 196 (208 ± 76.7) minutes ( P < 0.01), estimated blood loss was 50 (80 ± 92.1) versus 20 (43 ± 57.1) mL ( P = 0.07), and length of stay was 1 (3 ± 5.4) versus 1 (2 ± 1.9) day ( P = 0.57); 1 LESS operation was converted to “open.” Operative duration was longer for men ( P = 0.01). Postoperative complications were not more frequent after Nissen (n = 36) or Toupet (n = 28) fundoplication, regardless of the approach. When matched by BMI, operative duration was prolonged by a large Type I to IV hiatal hernia ( P = 0.01). Symptoms improved dramatically and were similar with both approaches, and patient satisfaction was high. Robotic redo antireflux operations take longer than LESS operations. LESS and robotic redo antireflux operations are both safe and offer significant and similar amelioration of symptoms after failed fundoplications.
Collapse
Affiliation(s)
| | - Danielle Craigg
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Miguel Castro
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Sharona Ross
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
| | - Iswanto Sucandy
- From the Department of Surgery, Florida Hospital Tampa, Tampa, Florida
| | | |
Collapse
|
20
|
Panda N, Rattner DW, Morse CR. Third-time ("redo-redo") anti-reflux surgery: patient-reported outcomes after a thoracoabdominal approach. Surg Endosc 2019; 34:3092-3101. [PMID: 31388809 DOI: 10.1007/s00464-019-07059-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/31/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Approximately 3-6% of patients undergoing anti-reflux surgery require "redo" surgery for persistent gastroesophageal reflux disease (GERD). Further surgery for patients with two failed prior anti-reflux operations is controversial due to the morbidity of reoperation and poor outcomes. We examined our experience with surgical revision of patients with at least two failed anti-reflux operations. METHODS Adults undergoing at least a second-time revision anti-reflux surgery between 1999 and 2017 were eligible. The primary outcomes were general and disease-specific quality-of-life (QoL) scores determined by Short-Form-36 (SF36) and GERD-Health-Related QoL (GERD-HRQL) instruments, respectively. Secondary outcomes included perioperative morbidity and mortality. RESULTS Eighteen patients undergoing redo-redo surgery (13 with 2 prior operations, 5 with 3 prior operations) were followed for a median of 6 years [IQR 3, 12]. Sixteen patients (89%) underwent open revisions (14 thoracoabdominal, 2 laparotomy) and two patients had laparoscopic revisions. Indications for surgery included reflux (10 patients), regurgitation (5 patients), and dysphagia (3 patients). Intraoperative findings were mediastinal wrap herniation (9 patients), misplaced wrap (2 patients), mesh erosion (1 patient), or scarring/stricture (6 patients). Procedures performed included Collis gastroplasty + fundoplication (6 patients), redo fundoplication (5 patients), esophagogastrectomy (4 patients), and primary hiatal closure (3 patients). There were no deaths and 13/18 patients (72%) had no postoperative complications. Ten patients completed QoL surveys; 8 reported resolution of reflux, 6 reported resolution of regurgitation, while 4 remained on proton-pump inhibitors (PPI). Mean SF36 scores (± standard deviation) in the study cohort in the eight QoL domains were as follows: physical functioning (79.5 [± 19.9]), physical role limitations (52.5 [± 46.3]), emotional role limitations (83.3 [± 36.1]), vitality (60.0 [± 22.7]), emotional well-being (88.4 [± 8.7]), social functioning (75.2 [± 31.0]), pain (66.2 [± 30.9]), and general health (55.0 [± 39.0]). CONCLUSION An open thoracoabdominal approach in appropriately selected patients needing third-time anti-reflux surgery carries low morbidity and provides excellent results as reflected in QoL scores.
Collapse
Affiliation(s)
- Nikhil Panda
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA, 02114, USA.
| | - David W Rattner
- Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Christopher R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients. RECENT FINDINGS A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.
Collapse
Affiliation(s)
- Semeret Munie
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Hassan Nasser
- Department of General Surgery, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
| | - Jon C Gould
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| |
Collapse
|