Intra-operative Complications in Patients Undergoing First Redo vs Repeat Redo Anti-reflux Surgery

Harit Kapoor, MBBS, Pradeep Pallati, MD, Shunsuke Akimoto, MD, Kalyana Nandipatti, MD, Tommy H Lee, MD, Sumeet K Mittal, MD. Creighton University

Background: A subset of patients with anti-reflux surgery require re-operative intervention. Re-operative intervention is associated with higher intra-operative complications when compared to primary fundoplication. Some patients may have recurrent failure and may require re-intervention which may have an even higher risk of complications. The aim of this study was to compare the patterns of intraoperative complications in patients who underwent first redo-anti-reflux surgery (Group A) with those who underwent re-operative anti-reflux surgery after at least one previous failed redo procedure (Group B) at our institution.

Methods: All patients undergoing anti-reflux procedures are entered in a prospectively maintained database. After Institutional Review Board approval, database was reviewed to identify patients who underwent redo-anti-reflux surgery between July 2003 and July 2014. These patients were divided into two groups, one group who underwent their first redo procedure (Group A) and another group with patients who underwent their 2nd (or greater) redo anti-reflux procedure (Group B). Data variables analyzed include demographics, surgical technique, operative time, estimated blood loss, hospital stay and intraoperative injuries which include perforation, solid organ injury and vagal injury. Chi square test and t-tests were used to compare the various variables among the groups.

Results: A total of 285 (254 with first redo, 24 with second redo, 5 with third redo and 1 each with fourth and fifth redo) underwent re-operative intervention during the study period. Group A had 254 patients (Redo-fundoplication, 69%; Redo-Roux-n-Y, 31%) and Group B had 31 patients (Redo-fundoplication, 64.5%; Redo-Roux-n-Y, 35.5%). Both groups had similar mean ages, BMI and sex distribution. There was no significant difference in the types of fundoplication performed and approach utilized in either group. Greater number of patients had esophageal shortening in group B (16.1% vs 9.1%). Group B had significantly higher mean intraoperative time (224 min vs 202.9 min; p<0.01) and estimated blood loss (397.5 ml vs 307 ml; p<0.01). Among complications, the rates of intra-operative visceral perforations were significantly higher in group B (48% versus 20.9%; p<0.01) while there is no significant difference in the number of reported vagal injuries or solid organ injuries between the two groups. The median hospital stay was significantly longer in group B as compared to group A (7 d vs 3 d; p<0.01).

Conclusion: Rate of intraoperative perforations and blood loss are significantly higher in patients undergoing their second (or greater) redo-anti-reflux surgery when compared with patients undergoing first redo-anti-reflux procedure.

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