Failed fundoplications

Department of Surgery, University of Utah, 30N 1900E, Salt Lake City, UT 84132, USA.
The American Journal of Surgery (Impact Factor: 2.29). 01/2005; 188(6):786-91. DOI: 10.1016/j.amjsurg.2004.08.062
Source: PubMed


Five percent of patients who undergo fundoplication will require reoperation. The cause of this high failure rate and the best management for these patients remains poorly understood. The aim of this study was to identify patterns and causes of failure of primary antireflux procedures.
Retrospective review of the medical records of patients who underwent revisional antireflux surgery at 2 tertiary referral centers.
Between 1998 and 2003, 39 patients underwent laparoscopic revisional antireflux surgery. The time between primary and revisional surgery was 5.9 +/- 0.4 years. Primary operations included 26 laparoscopic and 13 open fundoplications. All of the 39 revisional operations were attempted laparoscopically, and there was 1 open conversion. Revisional procedures included 31 Nissen and 8 partial fundoplications. The duration of surgery was 138 +/- 10 minutes. Length of hospital stay was 2.1 +/- 0.3 days. At a mean follow-up of 6 months, reflux resolved in 94% of patients. Morbidity occurred in 23% of patients. Four types of failure were identified: type 1 = herniation of the gastroesophageal junction through the hiatus with or without the wrap (n = 21); type 2 = paraesophageal hernia (n = 9); type 3 = malformation of the wrap (n = 2). Six patients had primary wrap failure, and 1 had esophageal dysmotility.
Laparoscopic revisional antireflux surgery is effective treatment for patients with failed primary fundoplications. Successful revisional surgery depends on identification and correction of the reason for primary fundoplication failure.

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    • "Minimally invasive antireflux operations are commonly performed by many pediatric surgeons with a high degree of efficacy in treating gastroesophageal reflux disease refractory to medical management [1-6]. The most significant complication of this operation and the main reason these patients will require a second operation appears to be transmigration of the wrap through the esophageal hiatus [7] [8] [9]. As the Nissen wrap migrates into the lower mediastinum, it enlarges the esophageal hiatus. "
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    ABSTRACT: There are a number of reports in the literature describing the need for a redo fundoplication in patients who have previously undergone open fundoplication. However, these data are not well characterized in our current era of laparoscopic surgery. The purpose of this report is to document the management of patients requiring a redo fundoplication who originally underwent a laparoscopic Nissen fundoplication. After internal review board approval, the senior surgeon performed a retrospective chart review on all patients undergoing laparoscopic fundoplication between January 2000 and April 2006. Data collected included the patient's age, sex, neurologic impairment, need for gastrostomy, time interval between the initial and redo fundoplication, operative approach for the redo fundoplication, use of a biologic patch for the redo procedure, and length of follow-up. Two hundred seventy-three patients underwent laparoscopic Nissen fundoplication by the senior author during this time interval. Twenty-one patients have required a redo fundoplication and repair of the enlarged hiatus after laparoscopic fundoplication. No patient has undergone a redo procedure without the development of transmigration of the fundoplication wrap. A redo operation was performed without mesh in 13 patients, of which there were 4 recurrences (31%). The other 8 cases were repaired with Surgisis (Cook, Inc, Bloomington, Ind), and none of these have recurred, with a minimum of 11 months' follow-up and a mean follow-up of 26 months. In the 4 patients requiring a second redo procedure, the enlarged esophageal hiatus was reinforced with Surgisis, and none of these cases have recurred, with a minimum of 3 years' follow-up. Our data support the use of a biosynthetic mesh to reinforce the crural closure during the repair of iatrogenic hiatal hernias in children.
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    ABSTRACT: Background/Purpose: In adults, laparoscopic Nissen fundoplication is a very popular antireflux technique. Its advantage over the traditional open approach is manifold. The use of this technique in children is growing slowly but surely. The aim of this work is to report our initial experience with laparoscopic Nissen fundoplication in children. Materials and Methods: A total of 13 (including 3 neurologically impaired) patients underwent laparoscopic Nissen fundoplication in the period between 2002 and 2005 in the pediatric surgery department of Ain Shams University Hospitals. These patients data were reviewed retrospectively. Their age ranged between 6 months and 10 years. The mean period of follow-up was 1.5 years. All patients had documented gastroesophageal reflux disease. Indications for surgery included medically refractory reflux for more than 3 months. Results: Eleven patients were completed laparoscopically and two were converted into an open approach. There were no cases of visceral perforation, splenic injury or blood loss requiring blood transfusion. A laparoscopic gastrostomy was concomitantly performed in the neurologically impaired patients. Mean operative time was 188 minutes early in the course and 126 minutes in the last 3 cases. Resumption of regular feedings began on postoperative day 3.5 (mean). Mean date of discharge was postoperative day 4. Complications included conversion to open technique in two cases. Two patients developed postoperative temporary dysphagia and responded to medical treatment. Recurrence of symptoms occurred in 2 patients, one underwent an open Nissen fundoplication and the other responded to medical treatment. Conclusion: In our hands, laparoscopic Nissen fundoplication was a safe and effective treatment for children with GERD. Time to resume regular feeding, and hospital stay were comparable to other series. The low morbidity and absence of perioperative mortality would encourage us to perform the technique in the younger age groups (less than 3 months of age).
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