Failed Fundoplication Surgery

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Presentation from a postgraduate course for the 2011 meeting of the Society for Surgery on the Alimentary Tract Annual Meeting.

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Failed Fundoplication Surgery

  1. 1. Conflict of Interest / Disclosure• No financial or other relationship with any product or treatment discussed in this talk 1
  2. 2. Redo Anti-reflux Surgery: When and How SSAT Meet The Professor Luncheons May 9, 2011 Chicago, Illinois C. Daniel Smith 2
  3. 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. 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. 5. Redo ARS and PEH – Success is Possible307 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. 6
  7. 7. 1,892 10 fundo internal • Fundoplication failure 54 fail (2.8%) (reoperation) is unusual in1st redo fundoplication experienced hands 241 17 fail (7.1%) • Redo fundoplication can be2nd 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 management4th redo fundoplication 1 7
  8. 8. Failed ARS & PEH – Keys to Success• Know patterns of failure• Diagnostic work-up• Patient selection• Intraoperative management 8
  9. 9. ARS & PEH – Patterns of Failure 9
  10. 10. ARS & PEH – Patterns of Failure 10
  11. 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. 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 AspirationSlip / Misplaced Wrap Hiatal Hernia Heartburn Heartburn Chest Pain Chest Pain Regurgitation Regurgitation Dysphagia Dysphagia Nausea Nausea Bloating Bloating SOB SOB Aspiration Aspiration 12
  13. 13. ARS & PEH – Patterns of Failure 13
  14. 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 GESEntertain Other Diagnosis Redo Antireflux +/- G-tube 14
  15. 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. 16. Redo ARS & PEH – Patient SelectionNot everyone with failure should have a redoPresentation Redo?65 yo male, 6 years of goodresponse, now with recurrent HB Easy Yesand hiatal hernia with wrap undone32 yo female, never completelybetter after wrap, “loose wrap”, pH Noslightly increased 16
  17. 17. Two Predictors of Outcome Patient Selection Operative Technique 17
  18. 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. 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. 20. Redo ARS – Case 1Presentation3 yr ago LPH/N – GERD & Chest painNever better postop6 wks postop unable to swallow more than liquidsNow with persistent chest pain dysphagiaLost 30 poundsOp findingsLong tight wrapWrap on proximal stomachSuture tethering proximal stomach to right crusNo diverticulum 20
  21. 21. Redo ARS – Case 2PresentationLN 6 year ago – GERDBetter for 4 yearsNow with progressive dysphagia, CP, GERDEating makes things worse, GERD at nightNo bloatingOp findingsSlipped wrap now around gastric bodyProximal stomach in chest 21

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