SlideShare a Scribd company logo
1 of 15
Conflict of Interest /
             Disclosure
• No financial or other relationship with
  any product or treatment discussed in
  this talk




                                            1
Redo Anti-reflux Surgery:
    When and How

   SSAT Meet The Professor Luncheons




             May 9, 2011
            Chicago, Illinois

            C. Daniel Smith

                                       2
ARS & PEH – Failure Happens

• Anti-reflux Surgery Failure
     - 5-40%
     - Redo vs. back on PPIs

• PEH Failure
     - 25-40%
     - ? anatomic vs. clinical failure



                                               3
Failed ARS & PEH – Management Challenging

• What is failure?
• How to work-up?
• Decision about redo
• Intraoperative
    - Technically demanding
    - What to do (e.g., take down wrap, mesh, full wrap)


                                                           4
Redo ARS and PEH – Success is Possible

307 redo fundoplications                              1,892
                                                 1 fundo internal
                                                  0

     in 285 patients             187
                           1 fundo external
                            0
                                                              54 fail (2.8%)

                                              1st redo fundoplication
                                                        241
                                 42
                           1 redo external
                            st
                                                              17 fail (7.1%)

                                              2nd redo fundoplication
                                                         59
                                 2
                           2 redo external
                            st                                4 fail (6.8%)

                                              3rd redo fundoplication
                                                         6

                                                              1 fails (17%)

                                              4th redo fundoplication
                                                         1


                                                                               5
6
1,892
   10 fundo internal
                                •   Fundoplication failure
               54 fail (2.8%)       (reoperation) is unusual in
1st redo fundoplication             experienced hands
          241

               17 fail (7.1%)
                                •   Redo fundoplication can be
2nd redo fundoplication             done safely with the majority
           59
                                    of patients improved
               4 fail (6.8%)

3rd redo fundoplication
           6
                                •   Herniation of the fundus
                                    remains problematic - new
               1 fails (17%)
                                    strategies for management
4th redo fundoplication
           1




                                                                    7
Failed ARS & PEH – Keys to Success


• Know patterns of failure

• Diagnostic work-up

• Patient selection

• Intraoperative management


                                             8
ARS & PEH – Patterns of Failure




                                  9
ARS & PEH – Patterns of Failure




                              10
ARS & PEH – Patterns of Failure


• It all starts here

• Pattern of failure determines indication
 for surgery

• Correlate symptoms & diagnostics to
 pattern of failure

• Strong correlation predicts success
                                             11
ARS & PEH – Patterns of Failure
   Undone Wrap                          Tight Wrap / Crura
      Heartburn                             Heartburn
      Chest Pain                            Chest Pain
     Regurgitation                         Regurgitation
      Dysphagia                             Dysphagia
       Nausea                                Nausea
       Bloating                              Bloating
        SOB                                   SOB
      Aspiration                            Aspiration

Slip / Misplaced Wrap                     Hiatal Hernia
      Heartburn                             Heartburn
      Chest Pain                            Chest Pain
     Regurgitation                         Regurgitation
      Dysphagia                             Dysphagia
       Nausea                                Nausea
       Bloating                              Bloating
        SOB                                   SOB
      Aspiration                            Aspiration

                                                             12
ARS & PEH – Patterns of Failure




                              13
Prior Antireflux /
                            PEH Surgery
                                      EGD
                                      BaSw




            Anatomically                        Obvious Anatomic
              Normal                                Problem
                    pH
                   EMS
                                                                   Patterns
                   GES                             Symptom
                                                                      of
                                                   Correlatio      Failure
                                                       n
  No GERD            Confirm GERD                       EMS
                                                        GES


Entertain Other
  Diagnosis                             Redo Antireflux +/-
                                             G-tube


                                                                         14
Failed ARS & PEH – Work-up


• Read your own contrast GI studies

• See endoscopy directly (do
 endoscopy yourself or go to GI
 unit)

• No one better that you to recognize
 and correlate failure patterns


                                            15

More Related Content

More from C Daniel Smith

Re-engineering the Operating Room Using Variability Methodology to Improve He...
Re-engineering the Operating Room Using Variability Methodology to Improve He...Re-engineering the Operating Room Using Variability Methodology to Improve He...
Re-engineering the Operating Room Using Variability Methodology to Improve He...C Daniel Smith
 
Improving Surgical Safety and Patient Outcomes
Improving Surgical Safety and Patient OutcomesImproving Surgical Safety and Patient Outcomes
Improving Surgical Safety and Patient OutcomesC Daniel Smith
 
SureSELECT from PureFLOW-HC
SureSELECT from PureFLOW-HCSureSELECT from PureFLOW-HC
SureSELECT from PureFLOW-HCC Daniel Smith
 
Innovations in Foregut Surgery
Innovations in Foregut SurgeryInnovations in Foregut Surgery
Innovations in Foregut SurgeryC Daniel Smith
 
Advances in Managing GERD - LINX
Advances in Managing GERD - LINXAdvances in Managing GERD - LINX
Advances in Managing GERD - LINXC Daniel Smith
 
Innovations in Minimally Invasive Surgery 2011
Innovations in Minimally Invasive Surgery 2011Innovations in Minimally Invasive Surgery 2011
Innovations in Minimally Invasive Surgery 2011C Daniel Smith
 
Introducing Linx to Practice
Introducing Linx to PracticeIntroducing Linx to Practice
Introducing Linx to PracticeC Daniel Smith
 
Achalasia Surgery Update 2012
Achalasia Surgery Update 2012Achalasia Surgery Update 2012
Achalasia Surgery Update 2012C Daniel Smith
 
Surgical Options For GERD
Surgical Options For GERDSurgical Options For GERD
Surgical Options For GERDC Daniel Smith
 
FDA Advisory Panel Linx Presentation 011112
FDA Advisory Panel Linx Presentation 011112FDA Advisory Panel Linx Presentation 011112
FDA Advisory Panel Linx Presentation 011112C Daniel Smith
 

More from C Daniel Smith (12)

Re-engineering the Operating Room Using Variability Methodology to Improve He...
Re-engineering the Operating Room Using Variability Methodology to Improve He...Re-engineering the Operating Room Using Variability Methodology to Improve He...
Re-engineering the Operating Room Using Variability Methodology to Improve He...
 
Improving Surgical Safety and Patient Outcomes
Improving Surgical Safety and Patient OutcomesImproving Surgical Safety and Patient Outcomes
Improving Surgical Safety and Patient Outcomes
 
SureSELECT from PureFLOW-HC
SureSELECT from PureFLOW-HCSureSELECT from PureFLOW-HC
SureSELECT from PureFLOW-HC
 
Innovations in Foregut Surgery
Innovations in Foregut SurgeryInnovations in Foregut Surgery
Innovations in Foregut Surgery
 
Advances in Managing GERD - LINX
Advances in Managing GERD - LINXAdvances in Managing GERD - LINX
Advances in Managing GERD - LINX
 
Innovations in Minimally Invasive Surgery 2011
Innovations in Minimally Invasive Surgery 2011Innovations in Minimally Invasive Surgery 2011
Innovations in Minimally Invasive Surgery 2011
 
Introducing Linx to Practice
Introducing Linx to PracticeIntroducing Linx to Practice
Introducing Linx to Practice
 
Achalasia Surgery Update 2012
Achalasia Surgery Update 2012Achalasia Surgery Update 2012
Achalasia Surgery Update 2012
 
New Offering for GERD
New Offering for GERDNew Offering for GERD
New Offering for GERD
 
Surgical Options For GERD
Surgical Options For GERDSurgical Options For GERD
Surgical Options For GERD
 
FDA Advisory Panel Linx Presentation 011112
FDA Advisory Panel Linx Presentation 011112FDA Advisory Panel Linx Presentation 011112
FDA Advisory Panel Linx Presentation 011112
 
Paetau mie 090211
Paetau mie 090211Paetau mie 090211
Paetau mie 090211
 

Recently uploaded

Shazia Iqbal 2024 - Bioorganic Chemistry.pdf
Shazia Iqbal 2024 - Bioorganic Chemistry.pdfShazia Iqbal 2024 - Bioorganic Chemistry.pdf
Shazia Iqbal 2024 - Bioorganic Chemistry.pdfTrustlife
 
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar  💯Call Us 🔝 8005736733 🔝 💃  Top Class Call Gir...Kolkata Call Girls Shobhabazar  💯Call Us 🔝 8005736733 🔝 💃  Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...Namrata Singh
 
Intramuscular & Intravenous Injection.pptx
Intramuscular & Intravenous Injection.pptxIntramuscular & Intravenous Injection.pptx
Intramuscular & Intravenous Injection.pptxsaranpratha12
 
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...Sheetaleventcompany
 
Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...
Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...
Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...Sheetaleventcompany
 
Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...
Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...
Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...Sheetaleventcompany
 
Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...
Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...
Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...Sheetaleventcompany
 
Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...
Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...
Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...Sheetaleventcompany
 
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Sheetaleventcompany
 
Jual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan Cytotec
Jual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan CytotecJual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan Cytotec
Jual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan Cytotecjualobat34
 
❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...
❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...
❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...Sheetaleventcompany
 
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Sheetaleventcompany
 
👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...
👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...
👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...Sheetaleventcompany
 
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Sheetaleventcompany
 
Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...
Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...
Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...Angel
 
Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...GENUINE ESCORT AGENCY
 
Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...
Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...
Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...GENUINE ESCORT AGENCY
 
Electrocardiogram (ECG) physiological basis .pdf
Electrocardiogram (ECG) physiological basis .pdfElectrocardiogram (ECG) physiological basis .pdf
Electrocardiogram (ECG) physiological basis .pdfMedicoseAcademics
 
Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service Available
Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service AvailableCall Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service Available
Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service AvailableJanvi Singh
 
🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...
🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...
🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...soniya pandit
 

Recently uploaded (20)

Shazia Iqbal 2024 - Bioorganic Chemistry.pdf
Shazia Iqbal 2024 - Bioorganic Chemistry.pdfShazia Iqbal 2024 - Bioorganic Chemistry.pdf
Shazia Iqbal 2024 - Bioorganic Chemistry.pdf
 
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
Kolkata Call Girls Shobhabazar  💯Call Us 🔝 8005736733 🔝 💃  Top Class Call Gir...Kolkata Call Girls Shobhabazar  💯Call Us 🔝 8005736733 🔝 💃  Top Class Call Gir...
Kolkata Call Girls Shobhabazar 💯Call Us 🔝 8005736733 🔝 💃 Top Class Call Gir...
 
Intramuscular & Intravenous Injection.pptx
Intramuscular & Intravenous Injection.pptxIntramuscular & Intravenous Injection.pptx
Intramuscular & Intravenous Injection.pptx
 
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
Call Girl In Indore 📞9235973566📞 Just📲 Call Inaaya Indore Call Girls Service ...
 
Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...
Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...
Premium Call Girls Dehradun {8854095900} ❤️VVIP ANJU Call Girls in Dehradun U...
 
Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...
Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...
Pune Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Pune No💰Adva...
 
Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...
Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...
Jaipur Call Girl Service 📞9xx000xx09📞Just Call Divya📲 Call Girl In Jaipur No💰...
 
Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...
Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...
Premium Call Girls Nagpur {9xx000xx09} ❤️VVIP POOJA Call Girls in Nagpur Maha...
 
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
 
Jual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan Cytotec
Jual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan CytotecJual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan Cytotec
Jual Obat Aborsi Di Dubai UAE Wa 0838-4800-7379 Obat Penggugur Kandungan Cytotec
 
❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...
❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...
❤️Amritsar Escorts Service☎️9815674956☎️ Call Girl service in Amritsar☎️ Amri...
 
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
 
👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...
👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...
👉 Amritsar Call Girls 👉📞 8725944379 👉📞 Just📲 Call Ruhi Call Girl Near Me Amri...
 
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
Chandigarh Call Girls Service ❤️🍑 9809698092 👄🫦Independent Escort Service Cha...
 
Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...
Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...
Bandra East [ best call girls in Mumbai Get 50% Off On VIP Escorts Service 90...
 
Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...
Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...
 
Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...
Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...
Genuine Call Girls Hyderabad 9630942363 Book High Profile Call Girl in Hydera...
 
Electrocardiogram (ECG) physiological basis .pdf
Electrocardiogram (ECG) physiological basis .pdfElectrocardiogram (ECG) physiological basis .pdf
Electrocardiogram (ECG) physiological basis .pdf
 
Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service Available
Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service AvailableCall Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service Available
Call Girls Mussoorie Just Call 8854095900 Top Class Call Girl Service Available
 
🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...
🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...
🚺LEELA JOSHI WhatsApp Number +91-9930245274 ✔ Unsatisfied Bhabhi Call Girls T...
 

Failed Fundoplication Surgery

  • 1. Conflict of Interest / Disclosure • No financial or other relationship with any product or treatment discussed in this talk 1
  • 2. Redo Anti-reflux Surgery: When and How SSAT Meet The Professor Luncheons May 9, 2011 Chicago, Illinois C. Daniel Smith 2
  • 3. ARS & PEH – Failure Happens • Anti-reflux Surgery Failure - 5-40% - Redo vs. back on PPIs • PEH Failure - 25-40% - ? anatomic vs. clinical failure 3
  • 4. Failed ARS & PEH – Management Challenging • What is failure? • How to work-up? • Decision about redo • Intraoperative - Technically demanding - What to do (e.g., take down wrap, mesh, full wrap) 4
  • 5. Redo ARS and PEH – Success is Possible 307 redo fundoplications 1,892 1 fundo internal 0 in 285 patients 187 1 fundo external 0 54 fail (2.8%) 1st redo fundoplication 241 42 1 redo external st 17 fail (7.1%) 2nd redo fundoplication 59 2 2 redo external st 4 fail (6.8%) 3rd redo fundoplication 6 1 fails (17%) 4th redo fundoplication 1 5
  • 6. 6
  • 7. 1,892 10 fundo internal • Fundoplication failure 54 fail (2.8%) (reoperation) is unusual in 1st redo fundoplication experienced hands 241 17 fail (7.1%) • Redo fundoplication can be 2nd redo fundoplication done safely with the majority 59 of patients improved 4 fail (6.8%) 3rd redo fundoplication 6 • Herniation of the fundus remains problematic - new 1 fails (17%) strategies for management 4th redo fundoplication 1 7
  • 8. Failed ARS & PEH – Keys to Success • Know patterns of failure • Diagnostic work-up • Patient selection • Intraoperative management 8
  • 9. ARS & PEH – Patterns of Failure 9
  • 10. ARS & PEH – Patterns of Failure 10
  • 11. ARS & PEH – Patterns of Failure • It all starts here • Pattern of failure determines indication for surgery • Correlate symptoms & diagnostics to pattern of failure • Strong correlation predicts success 11
  • 12. ARS & PEH – Patterns of Failure Undone Wrap Tight Wrap / Crura Heartburn Heartburn Chest Pain Chest Pain Regurgitation Regurgitation Dysphagia Dysphagia Nausea Nausea Bloating Bloating SOB SOB Aspiration Aspiration Slip / Misplaced Wrap Hiatal Hernia Heartburn Heartburn Chest Pain Chest Pain Regurgitation Regurgitation Dysphagia Dysphagia Nausea Nausea Bloating Bloating SOB SOB Aspiration Aspiration 12
  • 13. ARS & PEH – Patterns of Failure 13
  • 14. Prior Antireflux / PEH Surgery EGD BaSw Anatomically Obvious Anatomic Normal Problem pH EMS Patterns GES Symptom of Correlatio Failure n No GERD Confirm GERD EMS GES Entertain Other Diagnosis Redo Antireflux +/- G-tube 14
  • 15. Failed ARS & PEH – Work-up • Read your own contrast GI studies • See endoscopy directly (do endoscopy yourself or go to GI unit) • No one better that you to recognize and correlate failure patterns 15
  • 16. Redo ARS & PEH – Patient Selection Not everyone with failure should have a redo Presentation Redo? 65 yo male, 6 years of good response, now with recurrent HB Easy Yes and hiatal hernia with wrap undone 32 yo female, never completely better after wrap, “loose wrap”, pH No slightly increased 16
  • 17. Two Predictors of Outcome Patient Selection Operative Technique 17
  • 18. Redo ARS & PEH – Operative Management • Start on left • Enter mediastinum from left & posterior • Open gastrohepatic well away from hiatus – “cheater plane” over caudate • Always take down prior wrap unless its your own and immediate hiatal herniation • Consider PEG if difficult dissection / large hernia 18
  • 19. Redo ARS & PEH – Summary • Failure happens • Become an expert diagnostician • Correlate symptoms & diagnositics to pattern of failure – beware no correlation • Technical execution in OR critical • Get help • Good outcomes are possible 19
  • 20. Redo ARS – Case 1 Presentation 3 yr ago LPH/N – GERD & Chest pain Never better postop 6 wks postop unable to swallow more than liquids Now with persistent chest pain dysphagia Lost 30 pounds Op findings Long tight wrap Wrap on proximal stomach Suture tethering proximal stomach to right crus No diverticulum 20
  • 21. Redo ARS – Case 2 Presentation LN 6 year ago – GERD Better for 4 years Now with progressive dysphagia, CP, GERD Eating makes things worse, GERD at night No bloating Op findings Slipped wrap now around gastric body Proximal stomach in chest 21