Minimally Invasive Esophageal Procedures

Marco G. Patti, MD, FACS

Disclosures

ACS Surgery 

Reoperation for GERD

At the UCSF Swallowing Center, an increasing number of patients are being seen for evaluation and treatment of foregut symptoms after laparoscopic antireflux surgery. These patients are treated as follows.

Some degree of dysphagia, bloating, and abdominal discomfort is common during the first 6 to 8 weeks after a fundoplication. If these symptoms persist or heartburn and regurgitation occur, a thorough evaluation (with barium swallow, endoscopy, esophageal manometry, and pH monitoring) is carried out with the aim of answering the following three questions:

  1. Are the symptoms attributable to persistent gastroesophageal reflux?

  2. Are the symptoms attributable to the fundoplication itself?

  3. Can the cause of the failure of the first operation be identified and corrected by a second operation?

Many patients report heartburn after a fundoplication. It is often assumed that this symptom must be the result of a failed operation and that acid-reducing medications should be restarted. In most cases, however, this assumption is mistaken: postoperative pH monitoring yields abnormal results in only about 20% of patients.[34] The value of manometry lies in its ability to document the changes caused by the operation at the level of the LES and the esophageal body. The pH monitoring assesses the reflux status and determines whether there is a correlation between symptoms and actual episodes of reflux. If abnormal reflux is in fact present, the therapeutic choice is between medical therapy and a second operation.

Other patients complain of dysphagia arising de novo after the operation. This symptom is usually attributable to the operation itself and may occur in the absence of abnormal reflux. In addition to manometry and pH monitoring, a barium swallow is essential to define the anatomy of the esophagogastric junction. A study from the University of Washington[35] found that the anatomic configurations observed could be divided into three main types: (1) type I hernia, in which the esophagogastric junction was above the diaphragm (subdivided into type IA, with both the esophagogastric junction and the wrap above the diaphragm, and type IB, with only the esophagogastric junction above the diaphragm); (2) type II hernia, a paraesophageal configuration; and (3) type III hernia, in which the esophagogastric junction was below the diaphragm and there was no evidence of hernia but in which the body of the stomach rather than the fundus was used for the wrap. In 10% of patients, however, the cause of the failure could not be identified preoperatively.[33]

Some patients present with a mix of postprandial bloating, nausea, and diarrhea. These symptoms may be the result of damage to the vagus nerves. Radionuclide evaluation of gastric emptying often helps quantify the problem.

Patient preparation (i.e., anesthesia, positioning, and instrumentation) for a reoperation for reflux is identical to that for the initial laparoscopic fundoplication.

I routinely attempt a second antireflux operation laparoscopically, but if the dissection does not proceed smoothly, I convert to a laparotomy. To provide a stepwise technical description that would be suitable for all reoperations for reflux is impossible because the optimal procedure depends on the original approach (open versus laparoscopic), the severity of the adhesions, and the specific technique used for the first operation (total or partial fundoplication). The key goals of reoperation for reflux are as follows.

  1. To dissect the wrap and the esophagus away from the crura. This is the most difficult part of the operation. The major complications seen during this part of the procedure are damage to the vagus nerves and perforation of the esophagus and the gastric fundus.

  2. To take down the previous repair. The earlier repair must be completely undone and the gastric fundus returned to its natural position. If the short gastric vessels were not taken down during the first procedure, they must be taken down during the second.

  3. To dissect the esophagus in the posterior mediastinum so as to have enough esophageal length below the diaphragm and avoid placing tension on the repair.

  4. To reconstruct the cardia. The same steps are followed as for a first-time repair. If, after extensive esophageal mobilization, the esophagogastric junction remains above the diaphragm (short esophagus), esophageal lengthening can be accomplished by adding a thoracoscopic Collis gastroplasty to the fundoplication. To date, however, I have never found this step to be necessary.

Because the risk of gastric or esophageal perforation or damage to the vagus nerves is much higher during a second antireflux operation, the surgeon must be ready to convert to a laparotomy if the dissection is too cumbersome or the structures are not properly identified. Most perforations are recognized and repaired intraoperatively. Leaks manifest themselves during the first 48 hours. Peritoneal signs are noted if the spillage is limited to the abdomen; shortness of breath and a pleural effusion are noted if spillage also occurs in the chest. The site of the leak should always be confirmed by means of a contrast study with barium or a water-soluble agent. Perforation is best handled with laparotomy and direct repair of the leak.

Whereas the success rate is around 80% to 90% for a first antireflux operation, it falls to 70% to 80% for a second such operation. In my view, a second operation should be attempted by an expert team only if medical management fails to control heartburn or pneumatic dilatation has not relieved dysphagia.

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