Laparoscopic Revisional Surgery for Recurrent GERD an d/or Hiatal Hernia

Hitoshi Idani, MD, Shinya Asami, MD, Kanyu Nakano, MD, Yohei Kurose, MD, Tetsushi Kubota, MD, Satoshi Komoto, MD, Shinichiro Kubo, MD, Hiroki Nojima, MD, Katsuyoshi Hioki, MD, Hitoshi Kin, MD, Norihisa Takakura, MD

Department of Surgery, Fukuyama City Hospital, Department of Gastrointestinal surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences

Background: Laparoscopic revisional surgery (LRS) for GERD and/or hiatal hernia is still technically challenging and its outcome has not been reported from Japan. We report surgical technique and initial results of LRS for recurrent GERD and/or hiatal hernia in our hospital.

Patients and methods: Medical charts of the patients underwent revisional surgery for recurrent GERD and/or hiatal hernia in our hospital were reviewed and data were corrected retrospectively. The type of recurrence, the type of surgery performed and its outcome were analyzed. The form of fundoplication was evaluated by our newly established morphological scoring system (M score: evaluated by the position and the straightness of the fundoplication by laparoscopy and endoscopy; 1-5) pre-and post-operatively.

Results: Between April 2005 and June 2012, a total of 14 patients (15 procedures) with recurrent GERD and/or hiatal hernia after laparoscopic fundoplication underwent revisional surgery. The patients consisted of six men and eight women with the mean age of 65 years (range 33-84). Types of primary fundoplication were 9 Nissen, 4 Toupet, 1 anterior and 1 Toupet after Nissen. Interval from the primary surgery was 30.5 (range 3-116) months. Causes of recurrence included 11 sliding hernia, 3 paraesophageal hernia and 1 gastric dysmotility. Laparoscopic surgery was performed on 14 patients and open surgery was on one. Revisional surgery included hernia repair with mesh for 1, redo Nissen for 3 (with pyloroplasty: 1) redo Toupet for 6 (with mesh: 3), redo lateral fundoplication with mesh for 1. Five patients were converted from Nissen to Toupet fundoplication since floppy Nissen could not be performed properly because of thickened gastric fundus. Open partial gastrectomy was performed on one patient with acute incarcerated paraesophageal hernia with strangulation. One patient required the 3rd operation for recurrence after redo fundoplication. Operation time was 226±45min and conversion to open surgery was required on 3 (21.4%) patients. Soft diet started on the first POD and post-operative stay was 5.7days. M score was significantly improved after revisional surgery (from 1.6±0.2 to 4.2±0.2, p=0.000002). There were no complications except for one IVC injury which occurred during the 3rd operation, which was repaired by open surgery. With the median follow up period of 42 months, 11 patients have been without recurrence and 2 patients have been well controlled with PPI. One patient undergoing the 3rd operation has mild dysphagia and heart burn.

Conclusion: LRS for recurrent GERD and/or hiatal hernia is feasible and effective and M score is useful for the evaluation of the form of the fundoplication during surgery. IVC injury is one of the most dangerous complications and care should be taken for it.

Session: Poster Presentation

Program Number: P210

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