Laparoscopic antireflux surgery and repair of hiatal hernia

Laparoscopic mobilization of the esophagus and esophagogastric (O-G) junction enables the safe and effective performance of endoscopic antireflux surgery for intractable reflux esophagitis. The two antireflux procedures that we have evaluated in clinical practice at this institution are the ligamentum teres cardiopexy (n=9) and partial posterior fundoplication (n=5). More recently, laparoscopic repair of large symptomatic hiatal hernia (sliding, paraesophageal, and mixed) has also been introduced (n=4). The procedure entails reduction of the hernia, mobilization of the O-G junction with crural repair by a continuous suture technique employing a special preformed jamming loop knot, followed by total fundoplication, which is fixed proximal to the anterior margin of the diaphragmatic hiatus and distal to the O-G junction. The early results (maximum follow-up 18 months) of this experience have been favorable, with minimal morbidity, early hospital discharge, and effective control of reflux symptoms without adverse sequelae. Laparoscopic antireflux surgery is an alternative to long-term medication in patients with intractable esophagitis, and laparoscopic repair of large hiatal hernias offers significant advantage over the conventional open surgical approach in terms of rapid convalescence.

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Resumen La movilización laparoscópica del esófago y de la union esofagogástrica (EG) hace posible la realización segura y eficaz de cirugía antirreflujo endoscópica para el manejo de la esofagitis de reflujo intratable. Los dos procedimientos antirreflujo que han sido valorados en la práctica clínica en esta institución son la cardiopexia con el ligamento redondo (n=9) y la fundoplicación parcial posterior (n=5). Más recientemente también se ha introducido la reparación laparoscópica de la hernia hiatal grande y sintomática (por deslizamiento, paraesofágica y mixta) (n=4). El procedimiento implica la reducción de la hernia, la movilización del la union EG con reparación de las cruras mediante técnica de sutura continua empleando un nudo de seguridad especial preatado, seguida de fundoplicación total que es fijada en la región proximal al margen anterior del hiato diafragmático y distalmente a la unión EG. Los primeros resultados (seguimiento máximo de 18 meses) de esta experiencia han demonstrado ser favorables, con minima morbilidad, egreso hospitalario temprano y control efectivo de los síntomas de reflujo sin secuelas adversas. La cirugia laparoscópica antirreflujo es una alternativa terapéutica frente al tratamiento médico a largo plazo en pacientes con esofagitis intratable, y la reparación laparoscópica de grandes hernias hiatales ofrece ventajas significativas, en términos de convalescencia rápida, sobre el abordaje abierto.

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Résumé La mobilisation, sous coelioscopie, de l'oesophage et de la jonction oesogastrique (JOG) permet d'envisager la chirurgie antireflux par voie coelioscopique pour oesophagite rebelle au traitement médical. Les deux procédés antireflux qui ont été évalués cliniquement dans notre unité sont la cardiopexie par le ligament rond (n=9) et la fundoplicature postérieure partielle (n=5). Plus récemment, on a réalisé par coelioscopie la cure de la hernie hiatale symptomatique (par glissement, paraoesophagienne, et mixte) (n=4). L'intervention comporte la réduction de la hernie, la mobilisation de la JOG, un rapprochement des piliers par un surjet en utilisant une technique spéciale de noeud préformé autobloquant suive d'une fundoplicature complète, fixée en haut à l'hiatus et en bas à la JOG. Les résultats précoces (suivi maximum de 18 mois) ont été favorables avec une morbidité minimale, une sortie précoce, et un bon contrÔle du reflux sans complication. La cure du reflux est une alternative au traitement médical au long cours et offre d'importants avantages sur la technique traditionnelle en termes de récupération rapide.

     

Laparoscopic refundoplications after failed antireflux surgery

BACKGROUND: Open and laparoscopic antireflux procedures may require reoperation for failures of the initial procedure in about 3% to 6% of cases. The purpose of this study is to describe our operative experiences, postoperative results, and patients' view of outcome following laparoscopic refundoplication. METHODS: Thirty patients (18 men, 12 women), mean age 56 years (range 37 to 77) underwent laparoscopic redo surgery. In 18 patients the initial surgery was done by the open technique, and 3 had surgery twice previously. Twelve patients had previous laparoscopic antireflux surgery. Indications for redo surgery were recurrent reflux (n = 17), dysphagia (n = 6), and the combination of both (n = 7). RESULTS: Twenty-eight patients were completed laparoscopically, 21 with a floppy Nissen and 7 with a Toupet fundoplication. Two patients were converted to the open procedure because of intraoperative technical problems. In 5 cases there was an injury to the stomach wall, successfully managed laparoscopically. Postoperatively 1 patient had dysphagia and required pneumatic dilatation, another had gas bloat. There was a significant increase in lower esophageal sphincter pressure at 3 months (12.4+/-4.8 mm Hg; n = 30) and 1 year (12.3+/-4.5 mm Hg; n = 30). Twenty-four hour pH monitoring showed a decrease of the DeMeester Score at 3 months after surgery from 14.7+/-10.6 (n = 30) and 1 year after surgery from 12.1+/-8.7 (n = 30). Gastrointestinal quality of life index increased from 87 points preoperatively to 121 at 3 months and 123 at 1 year, which is comparable with a healthy population (123 points). CONCLUSIONS: Laparoscopic refundoplication is a feasible and effective procedure with excellent postoperative results, independent of whether the primary procedure was done by the open or laparoscopic technique.     

Laparoscopic reoperation after failed antireflux surgery

INTRODUCTION: Laparoscopic surgery for the treatment of gastroesophageal reflux disease has been established as being safe, effective, and the best alternative to continuous life-long medical therapy. Antireflux surgery is not, however, devoid of complications and failures. Treatment of these patients represents a major challenge, especially when reoperation is indicated. PATIENTS: One-hundred consecutive patients had a reoperation in our clinic. Previous antireflux procedures were laparoscopic (52 patients), laparotomy (39 patients), and thoracotomy (9 patients). RESULTS: Peri- or postoperative complications occurred in 30 patients (30%). Operative complications were stomach perforation (14), significant bleeding (6), esophageal mucosal perforation (4), gastrocutaneous fistula (2), small bowel enterotomy followed by fistula (1), and tension pneumothorax (1). Reoperation was required in only 2 patients because of a missed stomach perforation or persistent chest leak. The conversion rate (from laparoscopic to open procedure) was 17% overall. CONCLUSION: Laparoscopic reoperation after a failed antireflux procedure is a major surgical challenge, and it is not devoid of morbidity. The surgeon must have extensive experience in laparoscopic surgery and should be able to perform reoperative open surgery through the abdomen and chest. Laparoscopic redo surgery is feasible with good results. Many patients in whom previous open surgery has failed enjoy the advantages of a laparoscopic redo procedure.     

Laparoscopic antireflux surgery: Tailoring the hiatal closure to the size of hiatal surface area

Background

The closure of the hiatal crura has proven to be a fundamental issue in laparoscopic antireflux surgery. In particular, the use of prosthetic meshes for crural closure results in a significantly lower rate of postoperative hiatal hernia recurrence with or without intrathoracic migration of the fundic wrap. The aim of the present study was to evaluate different methods of crural closure depending on the size of the hiatal defect by measuring the hiatal surface area.

Methods

Fifty-five consecutive patients (mean age = 53 years) with symptomatic gastroesophageal reflux disease (GERD) were scheduled for laparoscopic antireflux surgery (LARS) in our surgical unit. Intraoperatively, the length, breadth, and diameter of the hiatal defect was measured using an endoscopic ruler. In every patient, the hiatal surface area (HSA) was calculated using an arithmetic formula. Depending on the calculated HSA, hiatal closure was performed by (1) simple sutures, (2) simple sutures with a 1 × 3-cm polypropylene mesh, (3) simple sutures with dual Parietex^® dual mesh, or (4) “tension-free” polytetrafluoroethylene BARD Crurasoft^® mesh.

Results

Twenty-six patients (47.2%) underwent laparoscopic 360° “floppy” Nissen fundoplication. The remaining 29 patients (52.8%) with esophageal body motility disorder underwent laparoscopic 270° Toupet fundoplication. Mean calculated HSA in all patients was 5.092 cm². Thirty-two patients (58.2%) with a smaller hiatal defect (mean HSA = 3.859 cm²) underwent hiatal closure with simple sutures (mean number of sutures: = 2.0). In 12 patients (21.8%) with a mean HSA of 7.148 cm², hiatal closure was performed with a 1 × 3-cm polypropylene mesh in addition to simple sutures. Five patients with a mean HSA of 6.703 cm² underwent hiatal closure with Parietex mesh, and in the remaining six patients, who had a mean HSA of 8.483 cm², the hiatus was closed using BARD Crurasoft mesh. For a mean followup period of 6.3 months, only one patient (1.8%) developed a postoperative partial intrathoracic wrap migration.

Conclusion

Measurement of HSA with subsequent tailoring of the hiatal closure to the hiatal defect is an effective procedure to prevent hiatal hernia recurrence and/or intrathoracic wrap migration in laparoscopic antireflux surgery.

     

Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery

BACKGROUND: Laparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus. METHODS: A search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected. RESULTS: The results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure. CONCLUSIONS: Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.     

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: Quality of life, symptomatic outcome, and patient satisfaction

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) Underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluted using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Laparoscopic reoperations after failed and complicated antireflux operations

Nineteen patients underwent laparoscopic reoperations for failed or complicated antireflux operations from a total of 248 patients with gastroesophageal reflux disease who had been operated on by this approach. Sixteen had been submitted to open surgery and three to laparoscopic surgery over a period ranging from 5 days to 31 years before the study. Three patients had been submitted to two open antireflux surgeries previously. Seventeen patients had recurrent reflux esophagitis after different types of surgeries, and two patients presented with gastric strangulation after fundoplication. The causes of recurrence were: slipped total fundoplications (3), disruption of total and partial fundoplications (6), too-tight total fundoplication (1), too-low (gastric) partial fundoplication (1), Allison procedure (1), partial fundoplication and paraesophageal hernia (2), and unknown (3). The laparoscopic approach was used in 18 patients and a laparoscopic-thoracoscopic approach in 1. The procedures included laparoscopic total fundoplications (11), partial fundoplications (4), transhiatal esophagectomy (1), Collis-Nissen (1), Roux-en-Y gastrectomy and thoracoscopic vagotomy (1), and intrathoracic fundoplication (1). One patient was converted to open surgery. Intraoperative complications included 1 pneumothorax, 1 gastric perforation, and 1 esophageal perforation during the introduction of a Maloney dilator. Mean operative time was 210 min, ranging from 140 to 320 min. Mean hospital stay was 3.1 days after treatment of failed operations and 22 days after treatment of complications. Postoperative complications included subcutaneous infection (1), gastric fistula (1), and liver hematoma (1). The results have been excellent and good in 84.3% of the patients after a mean follow-up of 13 months. We concluded that laparoscopic reoperations are technically feasible with good preliminary results provided that the mandatory expertise is available.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Revisional surgery for failed antireflux surgery

The outcome and morbidity of revisional surgery after antireflux surgery has been suggested to be suboptimal compared with primary repair. Therefore, an individualized therapeutic approach based on exact analysis of the reasons for failure of the initial procedure is essential for successful management of these patients. This study attempts to summarize the management of this challenging patient population with a focus on the clinical presentation, causes of failure, evaluation, and variety and choice of revisional techniques.     

Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery

Background

Laparoscopic antireflux surgery (LARS) represents the gold standard in the treatment of gastroesophageal reflux disease with or without hiatal hernia. It offers excellent long-term results and high patient satisfaction. Nevertheless, several studies have reported a high rate of intrathoracic wrap migration or paraesophageal hernia recurrence. To reduce the incidence of this complication, the use of prosthetic meshes has been advocated. This study retrospectively evaluated the long-term results of LARS with or without the use of a mesh in a series of patients treated from 1992 to 2007.

Methods

From November 1992 to May 2007, 297 patients underwent laparoscopic antireflux surgery in the authors’ department. Crural closure was performed by means of two or three interrupted nonabsorbable sutures for 93 patients (group A), by tailored 3 × 4-cm polypropylene mesh placement for 113 patients (group B), and by nonabsorbable suture plus superimposed tailored mesh for 91 patients (group C).

Results

The mean follow-up period for the entire group was 95.1 ± 38.7 months, specifically 95.2 ± 49 months for group A, 117.6 ± 18 months for group B, and 69.3 ±.17.6 months for group C. Intrathoracic Nissen wrap migration or hiatal hernia recurrence occurred for nine patients (9.6%) in group A, two patients (1.8%) in group B, and only one patient (1.1%) in group C. Esophageal erosion occurred in only one case (0.49%). Functional results and the long-term quality-of-life evaluation after surgery showed a significant and durable improvement with no significant differences related to the type of hiatoplasty.

Conclusion

Over a long-term follow-up period, the use of a prosthetic polypropylene mesh in the crura for hiatal hernia proved to be effective in reducing the rate of postoperative intrathoracic wrap migration or hernia recurrence, with a very low incidence of mesh-related complications.     

Reoperation for failed antireflux surgery

The management of patients with an unsatisfactory result following antireflux surgery is often problematical. Ten such patients with failed antireflux surgery, for whom medical management had also subsequently failed, underwent reoperation via a thoraco-abdominal approach. The anatomical cause of the surgical failure was determined pre-operatively in most cases by endoscopy, radiology, manometry and 24-hour pH monitoring. The most common reason for failure was a slipped Nissen fundoplication. A tight wrap, a disrupted wrap and a fundoplication hernia were less common causes. At follow-up, only one patient had a poor result. Reoperation for failed antireflux surgery can yield good results and is facilitated by pre-operative definition of the cause of failure and wide operative exposure.     

三种抗胃食管反流手术治疗婴幼儿食管裂孔疝的评估

目的　以食管动力学和胃食管反流评估食管裂孔疝 3种抗反流手术疗效。方法　 41例食管裂孔疝中滑疝 15例、旁疝 3例、混合疝 2 3例。年龄 2个月～ 3岁 ,体重 5 .5～ 9 5kg。食管裂孔修补加Dor手术 2 8例 ,加Toupet手术 10例 ,仅做单纯裂孔修补 3例。全组进行了手术前、后食管动力及 2 4h食管pH监测。结果　术后随访 3～ 2 4个月 ,优良者 37例 (90 2 4% ) ,术后早期胃排空延迟 1例 (Toupet手术组 )GI示食管下段狭窄 5例 ,但有明显吞咽困难仅 1例 (未做胃底折叠术组 ) ,伤口裂开 1例 (Dor手术组 )。术后 3例仍有呕吐 (Dor手术组 ) ,3例复发 (2例Dor手术组 ,1例Toupet手术组 )。全组手术前后LESP改变不明显P >0 0 5 ,LESL术后明显增长 ,Dor手术组 (1 93± 0 6 1)cm ,Toupet手术组 (1 78± 0 44 )cm ,三组之间差异无显著性。旁疝混合疝组中用Dor手术修补术后LESL(2 13± 0 6 1)cm ,增长较Toupet手术修补更为显著 [(1 71± 0 49)cm ,P <0 0 5 ]。全组术后 2 4h食管pH监测参数明显改善 ,并以Toupet手术改善最显著。结论　三种抗反流手术均能有效减轻胃食管反流 ,以Toupet手术效果最佳。     

Laparoscopic revision of failed antireflux surgery: a systematic review

Background

Laparoscopic antireflux surgery is an accepted treatment for persistent gastroesophageal reflux but about 4% of patients will eventually require revision surgery.

Methods

We searched The Cochrane Collaboration, Medline, and EMBASE databases, augmented by Google Scholar and PubMed related articles from January 1, 1990, to November 22, 2010. Twenty studies met the inclusion criteria, reporting on 930 surgeries.

Results

The mean surgical duration was 166 minutes and conversion to open revision fundoplication was required in 7% of cases. Complications were reported in 14% of cases and the mean length of stay varied between 1.2 and 6 days. A good to excellent result was reported for 84% of surgeries and 5% of patients required a further revisional procedure.

Conclusions

Laparoscopic revision antireflux surgery appears to be feasible and safe, but subject to somewhat greater risk of conversion, higher morbidity, longer hospital stay, and poorer outcomes than primary laparoscopic fundoplication.     

Laparoscopic reoperation for failed antireflux procedures.

BACKGROUND: Laparoscopic fundoplication has become the criterion standard for the surgical treatment of gastroesophageal reflux disease. Recently, several patients were referred with recurrent symptoms of gastroesophageal reflux disease or severe dysphagia following previous antireflux surgery for possible laparoscopic reoperation. HYPOTHESIS: To determine the safety and efficacy of this procedure. DESIGN: Case series, consecutive sample. SETTING: University-affiliated and community tertiary care hospitals. PATIENTS: Prospective study of 27 consecutive patients undergoing attempted laparoscopic reoperation for symptoms of recurrent gastroesophageal reflux disease or intractable dysphagia following antireflux surgery. Patients were available for follow-up for 1 to 60 months postoperatively. INTERVENTIONS: All patients underwent preoperative workup and attempted laparoscopic reoperation for treatment of symptoms. MAIN OUTCOME MEASURES: Data were collected on preoperative symptoms and evaluation, operative time, blood loss, time to regular diet, length of hospitalization, morbidity, mortality, and long-term results. RESULTS: Twenty-six patients underwent successful laparoscopic operations, with no mortality and minimal morbidity. One patient underwent conversion to open laparotomy and then developed a proximal gastric leak, which was treated conservatively. Twenty-four patients began a liquid diet by postoperative day 1, and most were discharged from the hospital by postoperative day 3. One patient required dilation for postoperative dysphagia. The remaining patients are doing well and none have required treatment with acid-reducing medication. CONCLUSIONS: Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with excellent results. In the hands of experienced endoscopic surgeons, patients who have undergone unsuccessful antireflux surgery should be offered laparoscopic reoperation.