Sara E Martin del Campo, MD, MS, Andrew J Suzo, BS, Jeffrey W Hazey, MD, Kyle A Perry, MD. The Ohio State University Wexner Medical Center
INTRODUCTION: Redo fundoplication following failed anti-reflux surgery has been shown to improve patient symptoms; however, its impact on patient quality of life remains unclear. We hypothesized that laparoscopic redo fundoplication improves disease-specific and global quality of life in patients with recurrent symptoms following failed laparoscopic or open fundoplication.
METHODS AND PROCEDURES: A retrospective review of a prospective database was conducted for patients undergoing redo fundoplication between August 2009 and June 2014. Outcomes of interest included symptom and quality of life scores, operative time, blood loss, complications, and subsequent procedures. Reflux symptoms and quality of life were assessed using the validated Gastro-Esophageal Reflux Symptom Score (GERSS), Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire, and the global quality of life Short Form-36 (SF-36). Dysphagia was measured on a 5 point Likert scale. Initial post-operative data were collected in the clinic setting, and follow-up was obtained by telephone questionnaire, with a median follow-up interval of 14.5 (2-40) months. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate, and a p-value of <0.05 was considered statistically significant.
RESULTS: Forty-six patients underwent laparoscopic redo fundoplication during the study period, 8 (17%) following open fundoplication. Mean age was 46 ± 13 years, with a mean BMI of 29.5 ± 5.7 kg/m2, and 36 (78%) patients were female. Patients underwent surgery for symptomatic recurrent paraesophageal hernia (n=11, 24%), recurrent GERD (n=18, 39%), or postoperative dysphagia (n=17, 37%), and the median time to reoperation was 3.5 (0-14) years. Mean operative time following laparoscopic repair was 139 ± 41 minutes compared to 163 ± 51 minutes following open fundoplication (p=0.16). The median length of stay was 2 (1-15) days, and did not differ between patients with previous laparoscopic or open fundoplication. There were no perioperative mortalities, and one patient required conversion to an open procedure following previous laparoscopic fundoplication. Overall, 8 (17.3%) patients experienced complications, including 1 patient following previous open fundoplication. Two patients with previous laparoscopic fundoplication required reoperation. Seventy-five percent of patients reported significant dysphagia at baseline compared to 25% post-operatively (p=0.004). Median dysphagia scores decreased from 4.5 (0-5) to 1 (0-5, p=0.023), and 9 (20%) patients underwent an endoscopic dilation following redo fundoplication. GERSS improved from 41 (2-68) at baseline to 10 (0-55) at follow-up (p<0.001), and GERD-HRQL scores improved from 30 (3-47) at baseline to 6 (0-45) at follow-up (p<0.001). SF-36 scores demonstrated a significant improvement in general health (p=0.016) and a trend toward improved physical function (p=0.079) in the post-operative period, but these improvements were not statistically significant at longer-term follow-up. Overall, 89% of patients reported satisfaction with their operation, and 95% reported that they would have the operation performed again given the benefit of hindsight.
CONCLUSIONS: While associated with long operative times and significant complications, laparoscopic redo fundoplication produces durable improvement in reflux symptoms and disease-specific quality of life, as well as high patient satisfaction in patients following failed laparoscopic or open fundoplication.