Thursday, October 06, 2011

Reflux Surgery Redos Safe; Outcomes Not Always Optimal

By: MIRIAM E. TUCKER, Internal Medicine News Digital Network

Reoperation for failed antireflux surgery can be performed safely in experienced centers, but outcomes are not as good as with primary operations, according to the results of two new analyses.

Dr. Nicholas R.A. Symons of Imperial College, London, and his associates performed a systematic literature review of 20 studies comprising 930 operations in 922 patients. "We can conclude that laparoscopic revision antireflux surgery, when performed in units with an interest in this type of surgery, is feasible and safe but subject to somewhat greater risk of conversion, higher morbidity, longer hospital stay, and poorer outcomes than primary laparoscopic fundoplication," the researchers wrote in the American Journal of Surgery (2011;202:336-43).

Similarly, based on their retrospective study of 275 patients, Dr. Omar Awais of the University of Pittsburgh and his associates said, "Redo antireflux surgery can be performed safely in experienced centers, and as expected, the outcomes after redo antireflux surgery are not as good as [those of] first-time procedures. The operative approach depends on the underlying cause of failure" (Ann. Thorac. Surg. 2011;92:1083-90).

"Redo surgery after failed fundoplication is a complex operation."

Laparoscopic procedures are considered the gold standard treatment for severe gastroesophageal reflux because they appear to be more efficacious and less expensive than an open approach. Nonetheless, between 2.8% and 4.4% of patients who undergo laparoscopic fundoplication at a specialist center will require late reoperation for persistent or recurrent symptoms, and there may be an increased revision rate after primary laparoscopic antireflux surgery compared with an initial open approach. Revision of failed antireflux surgery increasingly is being performed laparoscopically, but data about this approach are limited, Dr. Symons and his associates noted.

Their analysis included 19 case-control series and one prospective case-control study. Patients ranged in age from 13 to 83 years, and 57% were female. Of the 8 articles in which the mean time between initial fundoplication and revision was given, the mean interval was 45.5 months (range 2-360 months). Of 12 studies noting the number of previous fundoplications the patients had undergone, 47 procedures (6.9%) were second reoperations and 9 (1.3%) were third reoperations.

Of the 18 studies documenting the type of initial surgery, 62% were laparoscopic, 35% were performed via laparotomy, 3% via thoracotomy, and 0.2% using video-assisted thoracoscopic surgery. Nissen fundoplication and Toupet partial fundoplication were the most common initial and revision procedures. Reflux/heartburn, experienced by 61% of patients, and dysphagia in 31% were the most common indications for laparoscopic reoperation, the investigators reported. Surgical duration, reported in 13 of the case series, ranged from 55 to 246 minutes, with an overall mean of 166 minutes for 721 patients. Previous studies have shown longer surgical times when the initial surgery was done laparoscopically compared with previous laparotomy, and also for revision surgery compared with primary surgery, Dr. Symons and his associates noted.

The overall rate of conversion from laparoscopic reoperation to open surgery – reported in all the studies – was 7.2%, while the rate for patients who had more than one previous fundoplication was 19%. The most common reason for conversion, reported in 16 studies, was adhesions from previous surgery. The overall 7.2% conversion rate is higher than that noted for primary surgery (3.7%), "but is not excessive given the increased complexity of revision surgery," they commented.

Postoperative complications, reported from 18 studies, occurred in 14%, ranging from 0% to 44%. There were two deaths, both occurring in the same study. Pneumothorax was the most common complication, in 2% (14/810). Mean length of stay, reported in 18 studies, ranged from 1.2 to 6 days.

Satisfactory to excellent results were reported for 84% of the operations, while 5% of patients had a further antireflux procedure. There was no significant correlation between the number of cases in a series and the mean surgical duration, conversion rate, postoperative complication rate, or reoperation rate.

While revision laparoscopic fundoplication does not confer excessive morbidity, evidence for the efficacy of this procedure "is far less convincing, mainly owing to the mixture of reporting time points, inconsistency of end point definitions, and methods of assessment between studies. There appears to be a larger proportion of patients undergoing a re-revision surgery than after primary fundoplication," Dr. Symons and his associates commented.

"This review is based on data from highly specialized units and, for these results to be reproduced, revision laparoscopic antireflux surgery should be performed by surgeons with experience and special interest in both laparoscopic and esophagogastric surgery," they concluded.

The single-center study included patients who underwent minimally invasive reoperative surgery after failed fundoplication at the University of Pittsburgh Medical Center from 1996 to 2008. The 275 patients had a median age of 52 years (range 17-88 years), and 11.3% had had more than one prior antireflux surgery. As with the systematic review, the most common presenting symptoms were heartburn (64%) and dysphagia (49.5%). The median time from the prior operation to the redo operation was 36 months.

"We can conclude that laparoscopic revision antireflux surgery ... is feasible and safe but subject to somewhat greater risk of conversion."

Transmediastinal migration of the wrap or a recurrent hiatal hernia (64%) were the most common causes of failure of the prior antireflux operation. Esophageal shortening was noted in 43% of patients, and a defect in the crural repair was identified in 4.4%. The most common procedure during reoperation was a Nissen fundoplication with or without a Collis gastroplasty. Nearly all of the redo procedures (93%) were done with a minimally invasive approach. There were eight conversions to open surgery due to extensive adhesions or a recognized intraoperative perforation, Dr. Awais and his associates reported.

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