Redo-surgery after failed anti-reflux procedures. A single centre experience.
EAES Academy. Ceccarelli G. 07/05/22; 363180; P225
Dr. Graziano Ceccarelli
Contributions
Contributions
Abstract
Introduction:
Minimally invasive Nissen fundoplication is the most common procedure for gastroesophageal reflux disease (GERD) with or without associated hiatal hernia, presenting a failure rate of approximately 20% on long-term follow up. The most frequent failure causes are: persistent post-operative dysphagia (one in three patients), gas bloat syndrome, persistent-recurrent reflux symptoms and other complications. A part of these patients may be candidated to a redo anti-reflux surgery. This surgery may be may be performed using a minimally invasive approach too, but is technically challenging for the high rate of severe complications. Furthermore the best technique for redo surgery remains debatable: re-fundoplication, gastric bypass or gastric resection and others procedures.
Methods:
We reviewed our last 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary and 11 (3.4%) for revisional surgery. The revisional surgery (RS) serie included 7 females and 4 males, a mean age of 57.6 years (43-71), a BMI>30 in 4 cases. In all the cases the previous surgery was a Nissen fundoplication. The average time from the primary surgery was of 42 months (7-108). The causes of post-operative failure were: stomach hernation, wrap deishence, valve telescoping, a too narrow wrap and upside down stomach. All procedures were performed by two surgeons expert in laaproscopy and in robotic surgery. Pre-operative investigations included endoscopy, esophageal pH /manometry study, esophago-gastric junction X-ray contrast study and in selected cases abdominal and chest CT scan (all cases for hiatal hernias).
Results:
All procedures were performed using a minimally invasive (10 using the robotic technique), no conversion to open surgery was registered.. The types of redo-surgery were: 9 redo-fundoplication (4 Nissen and 5 Toupet, 2 Roux-en-Y short-limb gastric by-pass), a hiatoplasty was performed in 8 cases and an absorbable mesh was used in 5 cases. One case was performed in emergency setting. Mean operative time was 147 min and mean hospital stay was 3.2 days (2-7). No Clavien-Dindo grade 3-4 were observed. One persistend post-operative dysphagia was registered in the follow-up.
Conclusions:
Redo antireflux surgery is indicated in selected patients. Minimally invasive surgery, both through laparoscopy or robotic approach, is feasible. Representing a challenging surgery if compared to primary surgery, it has to be performed in specialised centres. Robotic technology may represent a valid option to overcome any technical difficulties
Minimally invasive Nissen fundoplication is the most common procedure for gastroesophageal reflux disease (GERD) with or without associated hiatal hernia, presenting a failure rate of approximately 20% on long-term follow up. The most frequent failure causes are: persistent post-operative dysphagia (one in three patients), gas bloat syndrome, persistent-recurrent reflux symptoms and other complications. A part of these patients may be candidated to a redo anti-reflux surgery. This surgery may be may be performed using a minimally invasive approach too, but is technically challenging for the high rate of severe complications. Furthermore the best technique for redo surgery remains debatable: re-fundoplication, gastric bypass or gastric resection and others procedures.
Methods:
We reviewed our last 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary and 11 (3.4%) for revisional surgery. The revisional surgery (RS) serie included 7 females and 4 males, a mean age of 57.6 years (43-71), a BMI>30 in 4 cases. In all the cases the previous surgery was a Nissen fundoplication. The average time from the primary surgery was of 42 months (7-108). The causes of post-operative failure were: stomach hernation, wrap deishence, valve telescoping, a too narrow wrap and upside down stomach. All procedures were performed by two surgeons expert in laaproscopy and in robotic surgery. Pre-operative investigations included endoscopy, esophageal pH /manometry study, esophago-gastric junction X-ray contrast study and in selected cases abdominal and chest CT scan (all cases for hiatal hernias).
Results:
All procedures were performed using a minimally invasive (10 using the robotic technique), no conversion to open surgery was registered.. The types of redo-surgery were: 9 redo-fundoplication (4 Nissen and 5 Toupet, 2 Roux-en-Y short-limb gastric by-pass), a hiatoplasty was performed in 8 cases and an absorbable mesh was used in 5 cases. One case was performed in emergency setting. Mean operative time was 147 min and mean hospital stay was 3.2 days (2-7). No Clavien-Dindo grade 3-4 were observed. One persistend post-operative dysphagia was registered in the follow-up.
Conclusions:
Redo antireflux surgery is indicated in selected patients. Minimally invasive surgery, both through laparoscopy or robotic approach, is feasible. Representing a challenging surgery if compared to primary surgery, it has to be performed in specialised centres. Robotic technology may represent a valid option to overcome any technical difficulties
Introduction:
Minimally invasive Nissen fundoplication is the most common procedure for gastroesophageal reflux disease (GERD) with or without associated hiatal hernia, presenting a failure rate of approximately 20% on long-term follow up. The most frequent failure causes are: persistent post-operative dysphagia (one in three patients), gas bloat syndrome, persistent-recurrent reflux symptoms and other complications. A part of these patients may be candidated to a redo anti-reflux surgery. This surgery may be may be performed using a minimally invasive approach too, but is technically challenging for the high rate of severe complications. Furthermore the best technique for redo surgery remains debatable: re-fundoplication, gastric bypass or gastric resection and others procedures.
Methods:
We reviewed our last 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary and 11 (3.4%) for revisional surgery. The revisional surgery (RS) serie included 7 females and 4 males, a mean age of 57.6 years (43-71), a BMI>30 in 4 cases. In all the cases the previous surgery was a Nissen fundoplication. The average time from the primary surgery was of 42 months (7-108). The causes of post-operative failure were: stomach hernation, wrap deishence, valve telescoping, a too narrow wrap and upside down stomach. All procedures were performed by two surgeons expert in laaproscopy and in robotic surgery. Pre-operative investigations included endoscopy, esophageal pH /manometry study, esophago-gastric junction X-ray contrast study and in selected cases abdominal and chest CT scan (all cases for hiatal hernias).
Results:
All procedures were performed using a minimally invasive (10 using the robotic technique), no conversion to open surgery was registered.. The types of redo-surgery were: 9 redo-fundoplication (4 Nissen and 5 Toupet, 2 Roux-en-Y short-limb gastric by-pass), a hiatoplasty was performed in 8 cases and an absorbable mesh was used in 5 cases. One case was performed in emergency setting. Mean operative time was 147 min and mean hospital stay was 3.2 days (2-7). No Clavien-Dindo grade 3-4 were observed. One persistend post-operative dysphagia was registered in the follow-up.
Conclusions:
Redo antireflux surgery is indicated in selected patients. Minimally invasive surgery, both through laparoscopy or robotic approach, is feasible. Representing a challenging surgery if compared to primary surgery, it has to be performed in specialised centres. Robotic technology may represent a valid option to overcome any technical difficulties
Minimally invasive Nissen fundoplication is the most common procedure for gastroesophageal reflux disease (GERD) with or without associated hiatal hernia, presenting a failure rate of approximately 20% on long-term follow up. The most frequent failure causes are: persistent post-operative dysphagia (one in three patients), gas bloat syndrome, persistent-recurrent reflux symptoms and other complications. A part of these patients may be candidated to a redo anti-reflux surgery. This surgery may be may be performed using a minimally invasive approach too, but is technically challenging for the high rate of severe complications. Furthermore the best technique for redo surgery remains debatable: re-fundoplication, gastric bypass or gastric resection and others procedures.
Methods:
We reviewed our last 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary and 11 (3.4%) for revisional surgery. The revisional surgery (RS) serie included 7 females and 4 males, a mean age of 57.6 years (43-71), a BMI>30 in 4 cases. In all the cases the previous surgery was a Nissen fundoplication. The average time from the primary surgery was of 42 months (7-108). The causes of post-operative failure were: stomach hernation, wrap deishence, valve telescoping, a too narrow wrap and upside down stomach. All procedures were performed by two surgeons expert in laaproscopy and in robotic surgery. Pre-operative investigations included endoscopy, esophageal pH /manometry study, esophago-gastric junction X-ray contrast study and in selected cases abdominal and chest CT scan (all cases for hiatal hernias).
Results:
All procedures were performed using a minimally invasive (10 using the robotic technique), no conversion to open surgery was registered.. The types of redo-surgery were: 9 redo-fundoplication (4 Nissen and 5 Toupet, 2 Roux-en-Y short-limb gastric by-pass), a hiatoplasty was performed in 8 cases and an absorbable mesh was used in 5 cases. One case was performed in emergency setting. Mean operative time was 147 min and mean hospital stay was 3.2 days (2-7). No Clavien-Dindo grade 3-4 were observed. One persistend post-operative dysphagia was registered in the follow-up.
Conclusions:
Redo antireflux surgery is indicated in selected patients. Minimally invasive surgery, both through laparoscopy or robotic approach, is feasible. Representing a challenging surgery if compared to primary surgery, it has to be performed in specialised centres. Robotic technology may represent a valid option to overcome any technical difficulties
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