Early Experience with Laparoscopic Nissen Fundoplication for Recurrent GERD After Transoral Incisionless Fundoplication

Kyle A Perry, MD, Jeffery L Eakin, MD, John G Linn, MD, Raymond P Onders, MD, Vic Velanovich, MD, W. Scott Melvin, MD. Center for Minimally Invasive Surgery, Department of Surgery, The Ohio State University, Columbus, OH; Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH; Division of General Surgery, Henry Ford Hospital, Detroit, MI

INTRODUCTION: Transoral incisionless fundoplication (TIF) has been employed for endoscopic treatment of gastroesophageal reflux disease. Full thickness polypropylene H-fasteners create a serosa to serosa gastroesophageal plication. A certain subset of TIF patients will require subsequent antireflux surgery to achieve adequate reflux control, and it is unknown whether this procedure increases the technical difficulty of laparoscopic Nissen fundoplication for recurrent GERD. The aim of this study was to evaluate the initial North American experience performing laparoscopic Nissen fundoplication following failed TIF procedure.

METHODS: Between 2008 and 2010, patients demonstrating objective evidence of recurrent gastroesophageal reflux following TIF using the Esophyx device (Endogastric Solutions Inc., Redmond, WA) underwent laparoscopic Nissen fundoplication. The study endpoints included operative time, operative blood loss, gastric or esophageal perforation, and length of hospital stay. All data are presented as median (range).

RESULTS: A total of 7 patients underwent laparoscopic Nissen fundoplication for recurrent GERD at a median interval of 7.0 (3-28) months after TIF. Revisional fundoplication required 97 (48-122) minutes and was performed in all cases with minimal blood loss. There were no cases of esophageal or gastric perforation during the dissection of the previous fundoplication. A significant hiatal hernia was noted during one case, and all others revealed partially disrupted gastroesophageal fundoplications with visible dislodged prolene H-fasteners visible. All patients were discharged from the hospital on the first postoperative day.

CONCLUSION: Severe recurrent gastroesophageal reflux necessitating laparoscopic Nissen fundoplication occurs in a subset of patients following TIF. In this series, previous TIF did not result in prolonged operative times, significant operative hemorrhage, or iatrogenic hollow viscus injury. These data suggest that laparoscopic Nissen fundoplication can be safely performed in this patient population without increased operative morbidity.

Session: SS01
Program Number: S003

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