Treatment of failures after antireflux surgery

Mario Costantini
Università di Padova – Clinica Chirurgica 1^
(Dir. Prof. E. Ancona)
Treatment of failures
after antireflux surgery
Background
• Laparoscopic fundoplication has revealed as a valid
alternative to medical treatment for GERD.
• The number of patients undergoing laparoscopic
fundoplication is continuously increasing.
• In the same way, failures of this therapy are
increasingly reported, also.
• A better knowledge of the mechanisms of failure and
of the related risk factors may help the surgeon
prevent and/or treat some of these failures.
Laparoscopic treatment of GERD
University of Padua – Clinica Chirurgica 1
(prof. Ermanno Ancona)
1992- June 2010:
595 pats.
387 Uncomplicated GERD
38 Severe esophagitis
80 Barrett
90 Large hernias (type II-III)
Age: 50 years (10Age:
(10-81)
M:F = 315: 233
Median follow up:
47 mos. (1-181)
65%
15.2%
13.4%
6.4%
GERD & Hiatal Hernia
Laparoscopic Treatment (1992 – 6/2010)
n = 595
60
50
40
30
20
Primary
Redos
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
0
1993
10
1992
n.
Failures of Laparoscopic Fundoplication
• Anatomical failure
– Fundoplication dislocation
• Recurrence of symptoms
– Recurrence of GERD
• Symptoms caused by surgery
– Persistent dysphagia
– Gas-bloat syndrome
• Unsatisfied patients
– Persistence of (a)-typical symptoms
Classification of Failures
• Dislocation of the fundoplication
• Recurrence of GERD
• Persistent dysphagia
• Gas-bloat syndrome
• Unsatisfied patients
(Persistent [a]-typical symptoms)
Causes of failure of fundoplications performed
open vs laparoscopically
Open
Lap
Cause of failure
(n=29) (n=71)
Transdiaphragmatic herniation
22
50.7
Fundoplication disruption
51
1.4
Slipped /misplaced fundoplication
22
18.3
Fundoplication too tight / too long
13
4.2
Achalasia
4
5.6
Twisted fundoplication
0
19.8
<.01
<.01
ns
ns
ns
<.01
Mod. from: Hunter et al, Ann Surg 1999
Causes of failure of previous
antireflux procedure (n=3,175)
Anatomical abnormalities:
Intrathoracic wrap migration
Telescoping
Wrap disruption
Para-esophageal hiatal herniation
Hiatal disruption
Tight wrap
Stricture
%
27.9
14.1
22.7
6.1
5.3
5.3
1.9
Mod. from: Furnée et al, JOGS 2009
42%
Dislocation of fundoplication
(slipping & telescoping)
41 patients (6.8%)
4 Early
(2°, 2°, 4° & 7° P.O.D.)
Re-operation
(1 open)
3 Healed
1 Dysphagia  dilations
 mesh penetration  EGP
Dislocation of fundoplication
(slipping & telescoping)
41 patients (6.8%)
37 Late (median 15.5 mos., 3-106)
6 Asymptomatic
31 Symptomatic
7 Medical therapy
Follow-up
24 Re-operations
19 Asymptomatic
3 Re-redos for dysphagia
2 Re-redos for recurrence
Recurrence of hernia (slipped & telescoping)
Surgical treatment
(n = 24)
• 6 laps redo-Nissen
• 15 laps redo-Nissen +
mesh (7“double face” –
5 PTFE); 3 PEG
• 1 laps redo-Toupet +
mesh
• 1 Collis-Nissen torac.
• 1 Merendino
Anatomical displacement of lap. fundoplication
Risk factors
Soper*
(20/290 -7%)
Hunter^
(31/857 -3.5% )
Large hiatal hernia
yes
no
Barrett’s esophagus
no
yes
Stricture
no
no
Early vomiting
yes
Diaphragm stressor
yes
n.e
n.e
Soper Ann Surg 1999; 229: 669-77
Hunter Ann Surg 1999 230: 595 -606
Laparoscopic treatment of GERD:
Results on 545 patients* (1992-2010)
100
p < 0.05
%
80
85.7
83.2
Slipped
Gas-bloat
Rec GERD
Dysphagia
Asymptomatic
71.8
60
40
20
0
Barrett
*strictures and short esophagus excluded
Uncomplicated
GERD
Paraesophageal
Hernias
Clinica Chirurgica - PD
Paraesophageal hernias: Mesh vs. non-mesh
Randomized prospective studies
30
% recurrence
25
20
Mesh
non-Mesh
15
10
5
0
Frantzides
Granderath
Oelschlager
Arch Surg 2002
Arch Surg 2005
Ann Surg 2006
PTFE
Key-hole
Polypropilene
1x3 patch
Biological
U-shaped
Laparoscopic repair of large type II-III hernia
Probability of remaining recurrence-free
100
Mesh
p=0.02
Percent
75
Non-Mesh
50
25
Median follow-up: 59 months (r:1-122)
0
0
12 24 36 48 60 72 84 96 108 120
Months
Zaninotto et al. World J Surg, 2007
Displacement of Laparoscopic Fundoplication
Prevention
“one ounce of prevention is worth a pound of cure
A. Intraoperative:
•
adequate closure of hiatus (mesh)
•
adequate mobilization of esophagus
(lap Collis-Nissen)
B. Postoperative:
•
no early vomiting (ondansetron)
•
no late diaphragmatic stressor
Classification of Failures
• Dislocation of the fundoplication
• Recurrence of GERD
• Persistent dysphagia
• Gas-bloat syndrome
• Unsatisfied patients
(Persistent [a]-typical symptoms)
Recurrence of GERD*
23 patients (4.1%)
3 with dislocation
17 Medical therapy
1┼
1 Enterix
1 open redo 3 Laps Redo
1 C-N laps Nissen + mesh
11 Asympt.
(Ac. M.I.)
6 Improved
Follow-up
2 good
2 Med. therapy
1 Good
* 50% pts had post-op pH studies
GERD Recurrence
Normal valve
Disrupted valve
A disrupted valve was found at endoscopy in
all cases of GERD Recurrence
Recurrence of GERD: Risk Factors
%
100
80
60
40
20
0
Uncomplicated
GERD
Esophagitis 3° Stricture
Barrett
p = N.S.
Recurrence of GERD: when to operate?
• Symptoms not controlled by medical therapy
• Presence of anatomical reason for failure
(fundoplication displacement)
• Association with dysphagia or pain
Classification of Failures
• Dislocation of the fundoplication
• Recurrence of GERD
• Persistent dysphagia
• Gas-bloat syndrome
• Unsatisfied patients
(Persistent [a]-typical symptoms)
Simptoms before laparoscopic
refundoplication
Recurrent reflux
Dysphagia
Dysphagia & re-reflux
Previous open
(n=20)
Previous lap
(n=31)
14 (70%)
15 (48.4%)
0
12 (38.7%
6 (30%)
4 (12.9%)
Granderath et al. Int J Colorectal Dis 2003
Persistent dysphagia (> 4 weeks)
35 patients (5.9%)
32 Endoscopic dilations
19 Asymptomatic
10 Re-operations
3 Improved
Asymptomatic
3 Re-operations
Asymptomatic
Persistent Dysphagia after LARS
Etiology in operated patients
• Too tight a fundoplication: 8 pts
• Fundoplication made with the body of
the stomach (not fundus): 2 pt
• Too tight a hiatoplasty: 2 pt (1 mesh)
• Mesh induced hiatal fibrosis: 1 pt
Re-operations
for dysphagia
13 Lap-Nissen
(2 with mesh)
1 open Toupet
8 lap Toupet
1 redo hyatoplasty
1 mesh reshapening
1 mesh removal
1 Heller Dor
Persistent dysphagia: Risks factors
100
60
%
%
80
40
60
p< 0.05
20
40
20
0
SGV undivided
SGV divided
0
Uncomplicated
GERD
Esophagitis
Stricture
Barrett
RR: 7.9 (2.3-27.5)
Persistent dysphagia
& Learning curve
12
% dysphagia
10
8
6
4
2
0
1992-'95
1996-'99
2000-'03
2004-'06
2007-'10
5/51
5/114
12/177
6/122
6/139
Persistent post-operative dysphagia
How to prevent it?
“one ounce of prevention is worth a pound of cure
• Mobilisation of the gastric fundus
(SGV division), Floppy Nissen
• Learning curve
• “Tailored” approach
(Toupet if defective esoph. motility?)
Classification of Failures
• Dislocation of the fundoplication
• Recurrence of GERD
• Persistent dysphagia
• Gas-bloat syndrome
• Unsatisfied patients
(Persistent [a]-typical symptoms)
Persistent (> 1 month) collateral symptoms
after laparoscopic fundoplication
Symptom
Gas -bloat
Reflux
Dysphagia
Reporting
Patients with
papers
symptom (n)
(out of 41)
16
(39%)
28
(68%)
32
(78%)
Total
operations
Rate
(%)
239
2,539
9.4
206
5,929
3.5
188
7,487
2.5
Carlson & Frantzides, J Am Coll Surg 2001
(Review of 10,735 cases reported in Literature)
Influence of Functional Bowel Disease on Outcome of Surgical
Antireflux Procedures (n=155)
Complications
IBS Patients
(%)
FBD Patients
(%)
Non-FBD
Patients (%)
Any poor post-operative outcome
(gastrointestinal)
53*
36#
23
Dysphagia requiring reoperation
6
8
10
Gas bloat
33*
18*
6
Recurrent heartburn
13
14
12
Recurrent asthma/cough
6
8
8
* p < 0.05
# p = 0.09
Axelrod et al., J Gastrointest Surgery, 2002
Total vs posterior partial fundoplication
Pooled data of 3 randomized studies
Total
fundoplication
Posterior
fundoplication
No. of patients
103
117
Dysphagia
23%
17%
Gas-related
.problems
16%
1% *
Recurrent reflux
4%
4%
Factor
* p < 0.01
Watson & Jamieson, in: Pearson, Esophageal Surgery, 2002
Gas bloating
7 patients (1.2%)
5 Pneumatic dilations
(cardias and/or pylorus)
2 Asymptomatic
1 Lost to FU
1 Medical therapy
3 Symptomatic
2 Medical therapy
2 Improvement
1 several redos
(in different Centers)
Poor
Asymptomatic
Gas-bloat syndrome
How to prevent it?
“one ounce of prevention is worth a pound of cure
• Accurate preoperative evaluation
• Gastric emptying studies
• “Tailored” approach
(Toupet if IBS or FBD symptoms
associate to GERD?)
Classification of Failures
• Dislocation of the fundoplication
• Recurrence of GERD
• Persistent dysphagia
• Gas-bloat syndrome
• Unsatisfied patients
(Persistent [a]-typical symptoms)
Unsatisfied patients sine materia
3 patients (0.6%)
All post-operative tests normal !
Preoperative evaluation:
-Atypical symptoms with heartburn and regurgitation
-Abnormal pH or Bilitec® monitoring
-Poor response to PPI therapy
Psychiatric evaluation:
Patient 1
Hypocondriac ideation with tendency to paranoid
interpretation
Patient 2
Childhood problems that the patient refused to further
investigate
Patient 3
Not done
Unsatisfied patients sine materia
How to avoid them?
Predictive factors of good outcome after fundoplication
24-h pH
Main
symptom
PPIs
response
Odds ratio
Normal
Normal
Abnormal
Abnormal
Abnormal
Atypical
Typical
Atypical
Typical
Typical
Low/none
Complete/partial
Complete/partial
Low/none
Complete/partial
1
16,7
17,7
27,2
89,8
Campos J. Gastrointest Surg 1999; 3:292-300
Unsatisfied patients sine materia
Preoperative prevention
“one ounce of prevention is worth a pound of cure
• Rule out other conditions mimiking GERD
• Rule out IBS and / or FBD
i.e.: extensive functional work up
• Detailed informed consent and patients’ education
• Beware of patients with
– Atypical symptoms
– Normal 24-h pH studies
– Urgency in requiring the operation
!
Reasons for failure and number of patients
requiring a revisional procedure
Total
% Re-do
surgery
% Medical
therapy
48
52
48
Displaced repair
24
92
8
Too tight wrap or hiatal closure
11
82
18
Esophageal motor disorder
10
80
20
Herniation
6
83
17
6
33
67
105
68
32
Cause of failure
Recurrent reflux symptoms:
Disruption of the repair
Dysphagia or rec. GER & dysphagia:
Disturbed gastric emptying:
Gastric denervation
TOTAL
mod. from: Stein et al, Am J Surg 1996
Reoperations for failure of antireflux surgery
Need for reoperation
Cause
Recurrence of hernia
(slipped or telescoping)
Fundoplication disruption
Too-tight a fundoplication
or hyatoplasty (± mesh)
Other
(gas-bloat, atypical symptoms)
Overall
Padova, Clin Chir 1 - 2010
Patients
(%)
Need for
Re-do
(%)
41 (6.9)
28
68.3
23 (3.8)
5
21.7
35 (5.9)
13
37.1
7 (1.2)
1
14.3
106 (17.8)
47
44.3
Reoperations for failure of antireflux surgery
Need for reoperation
Cause
Recurrence of hernia
(slipped or telescoping)
Fundoplication disruption
Too-tight a fundoplication
or hyatoplasty (± mesh)
Other
(gas-bloat, atypical symptoms)
Overall
Padova, Clin Chir 1 - 2010
Patients
(%)
Need for
Re-do
(%)
41 (6.9)
28
68.3
23 (3.8)
5
21.7
35 (5.9)
13
37.1
7 (1.2)
1
14.3
106 (17.8)
47
44.3
47/595 = 7.9%
Results of laparoscopic repair of failed antireflux surgery
Author
# Pats
Convers.
Morbidity
Mortality
Good results
Szwerc 1999
15
0%
0
0
87%
Watson 1999
27
55%
0
0
93%
Curet 1999
27
4%
7%
0
96%
Horgan 1999
31
10%
32%
0
87%
Luketich 2002
80
2.5%
20%
0
82%
Papasavas 2004
54
5.6%
18%
0
82%
Smith 2005
307
8%
14%
0.3%
93%
From: Luketich, in Pearson: Esophageal Surgery 3rd ed. 2008
Reoperations for failure of antireflux surgery
Results
Cause
Recurrence of hernia
(slipped or telescoping)
Fundoplication disruption
Too-tight a fundoplication or
hyatoplasty (± mesh)
Other
(gas-bloat, atypical symptoms)
Overall
Internal Referred
(n=47)
(n=39)
% good
results
28
21
75.6*
5
6
87.5
13
9
94.7#
1
3
50.0
47
39
80.3
* 1 EGP, 1 peptic stricture (after 10 yrs)  EGP
# 1 EGP & 1 jejunal interposition (Merendino)
Padova, Clin Chir 1 - 2010
Conclusions
• The laparoscopic treatment of hyatal hernia and
(complicated and uncomplicated) GERD is valid
and accepted by the scientific community and the
patients.
• The failure rate of such therapy depends on
different causes, and may reach 20% and more.
• However, only about half of these patients require
revisional surgery, having the others beneficial
effects from medical and endoscopic therapy.
Conclusions
Fundoplication dislocation is the most common
cause of failure of laparoscopic antireflux surgery:
• wider hyatal dissection
• less adhesions
• earlier mobilisation and return to daily
activities of the patients
• (large hyatal defects – giant hernias)
• (“short” esophagus)
• (pathology of muscle fibers of the crura?)
Conclusions
•
Persistent dysphagia is probably related to
incomplete mobilisation of the fundus and/or an
uncorrect surgical technique.
•
In general, the reflux control is achieved in
more than 90% of patients.
•
Beware of patients with atypical symptoms and
who do not respond to medical therapy.
•
Gastrointestinal symptoms may be aggravated
after fundoplication, but they are often present
and require proper evaluation also before the
operation.