Contemporary Outcomes of First-Time Laparoscopic Reoperative Fundoplication

Stephanie G Worrell, MD, Daniel S Oh, MD, Christina L Greene, MD, Jeffrey A Hagen, MD, Steven R DeMeester, MD. Keck School of Medicine, University of Southern California.

Introduction: Laparoscopic reoperation for a failed fundoplication has been associated with increased complications and worse outcomes compared to a first time operation. The aim of this study was to evaluate contemporary outcomes of initial laparoscopic redo antireflux operations to assess complications and success of the repair.

Methods: A retrospective chart review was performed of all patients who had a first-time laparoscopic reoperation for a failed antireflux procedure from May 2008 to August 2013.

Results: There were 52 patients (19 males and 33 females, median age 56 years) who underwent first-time laparoscopic re-operation after a prior antireflux procedure. The initial procedure was done at an outside hospital in 32 cases and at our facility in 20. The initial operation was performed laparoscopically in 94% (49/52) of patients. The median time from initial operation to reoperation was 4 years (range 1 month to 13 years). Reason for reoperation was a recurrent hiatal hernia and/or fundoplication disruption in 36 (69%), a slipped or misplaced fundoplication in 6 (12%), and persistent dysphagia in 10 patients (19%). Laparoscopic revisional hiatal hernia repair was performed in 39 patients (75%) and in 13 patients with no recurrent hernia only a redo fundoplication was performed. A redo Nissen fundoplication was performed in 33 patients and in 18 patients a previous Nissen was converted to a Toupet. A Collis gastroplasty was added to the fundoplication for a short esophagus in 14 patients (27%). The operation was completed laparoscopically in 94% of patients. Three patients were converted to open, two for dense adhesions around the hiatus and the third for concerns regarding the integrity of the staple line during a Collis gastroplasty. Minor post-operative complications developed in 7 patients (13%). The median hospital stay was 3 days (IQR 2-3). Symptomatic follow-up was available in 45 patients at a median of 8.5 months. Resolution of the presenting symptoms occurred in 93%. Objective follow-up was available by videoesophagram or upper endoscopy in 27 patients at a median of 12 months. There was one recurrent hernia with an intact fundoplication. Two patients needed a subsequent operation for symptomatic delayed gastric emptying.

Conclusions: First-time revisional laparoscopic antireflux surgery can be done safely with a low rate of complications or conversion to open laparotomy. The most common indication for redo fundoplication was a symptomatic recurrent hiatal hernia with or without a disrupted fundoplication. A short esophagus was frequently encountered, and in 27% of patients a Collis gastroplasty was necessary. Short term follow-up indicates excellent symptomatic improvement and a low rate of recurrent hernia.

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