Laparoscopic Revision Anti-Reflux Surgery for Prior Failed Transoral Incisionless Fundoplication is Safe – Technical Details.

Reginald Bell, MD, Kate Bell, NP, Carrie Morrison, PA, Ashwin A Kurian, MD. SurgOne Foregut Institute.

Transoral Incisionless Fundoplication (TIF) treats gastro-esophageal reflux disease (GERD) by creating full-thickness esophagogastric plications using transmural fasteners. Laparoscopic revision anti-reflux surgery for failed TIF has been reported, albeit with increased perforation risk secondary dissecting the transmural fasteners. We report the safety and efficacy of laparoscopic antireflux surgery in a series of patients with failed TIF.

All patients with a prior failed TIF undergoing laparoscopic revision anti-reflux surgery were analyzed prospectively. Data collected included patient demographics, pre-procedure clinical symptom scores, intraoperative and postoperative outcomes. Descriptive statistics were used to define the population.

Between 3/2009 and 8/2013, twenty-eight patients underwent laparoscopic revision of a prior TIF (mean age 55 years, 43 % males) at a mean 37 months post-TIF (range: 8-126). 71% underwent TIF primarily for typical GERD symptoms, the rest for extra-esophageal symptoms. 82% had initial improvement / resolution of symptoms, followed by recurrence motivating revision. Two patients had de novo chest pain post-TIF. All patients demonstrated abnormal pH testing prior to revision.
All revisions were completed laparoscopically with a mean duration of 88 +/- 18 minutes. Twenty patients underwent complete fundoplication; 8 patients underwent partial fundoplication. All patients were discharged by postoperative day 2. No intraoperative complications or postoperative leaks or abscesses occurred. Two patients required subsequent surgery, one for small paraesophageal hernia, one for refractory gas-bloat.

Operative findings: (1) Dense adhesions in 14% patients (2) Fasteners incorporating the lateral crus in 95% (3) Good residual anterior plication in 75%, although frequently free fasteners were observed medially. (4) Good residual posterior plication in 0%. (5) Traction diverticuli from esophagus to crura in 21%. (6) The anterior-posterior dimension of the hiatus was > 3cm in 90% of patients.

Operative approaches: (1) Areas where the fundus was fused to the esophagus were left intact. This necessitated rolling the fundoplication over the fused area to prevent an endoscopic appearance of intessusception. (2) Fasteners with one end free were left in-situ. (3) Fasteners between the lumen and another structure (e.g. esophagus and crura) were gently displayed, then cut and left to migrate into the lumen. (4) Seven patients with hiatal hernias underwent circumferential, level 1 mediastinal dissection and hiatal repair (5) In 8 patients with good intra-abdominal esophageal length, no significant hernia, and fusion of the lateral crus to TIF fundoplication, revision laparoscopic fundoplication was performed without mediastinal mobilization and the fused crura/fundoplication was left intact. (5) Traction diverticuli were divided, the fastener left in the esophageal lumen, and then oversewn.

Failure after TIF fundoplication leading to reoperation is associated with a hiatus > 3cm and complete loss of the posterior portion of the fundoplication. The anterior portion of the fundoplication and lateral crural fixation generally remain intact. Meticulous attention to technical detail obviates the perforation risk from the transmural fasteners. Laparoscopic revision anti-reflux surgery for failed TIF is feasible and safe.

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