Failed antireflux surgery: quality of life and surgical outcome after laparoscopic refundoplication

BACKGROUND AND AIMS: Laparoscopic antireflux surgery has in recent years become the standard procedure for treating severe gastroesophageal reflux disease. Both laparoscopic antireflux surgery and open surgery cause failures which lead to repeat surgery in 3-6% of cases. We evaluated prospectively quality of life and surgical outcome following laparoscopic refundoplication for failed initial antireflux surgery. PATIENTS AND METHODS: We prospectively studied 51 patients undergoing laparoscopic refundoplication for primary failed antireflux surgery, with complete follow-up 1 year after surgery. In 20 cases the initial surgery used the open technique; four had surgery twice previously. In 31 cases primary procedure was performed laparoscopically. Indication for repeat surgery were recurrent reflux ( n=29), dysphagia ( n=12), and a combination of the two ( n=10). Preoperative and postoperative data including 24-h pH monitoring, esophageal manometry, and quality of life (Gastrointestinal Quality of Life Index) were used to assess outcome. RESULTS: Forty-nine procedures (96%) were completed by the laparoscopic technique. Conversion was necessary in two cases with primary open procedure, in one patient because of injury to the gastric wall and in one severe bleeding of the spleen. Postoperatively two patients (3.9%) suffered from dysphagia and required pneumatic dilatation within the first postoperative year. Average operating time was 245 min after an initial open procedure and 80 min after an initial laparoscopic procedure. The lower esophageal sphincter pressure increased significantly from preoperatively 2.8+/-1.8 mmHg at 3 months (12.8+/-4.1 mmHg) and 1 year (12.3+/-3.9 mmHg) after repeat surgery. In these cases the DeMeester score decreased significantly from preoperative 67.9+/-10.3 to 15.5+/-9.4 at 3 months and 13.1+/-8.1 at 1 year after surgery. Mean Gastrointestinal Quality of Life Index increased from 86.7 points preoperatively to 121.6 points at 3 months and 123.8 points at 1 year and was comparable to that of a healthy population (122.6 points). CONCLUSION: Laparoscopic repeat surgery for recurrent or persistent symptoms of gastroesophageal reflux disease is effective and can be performed safely with excellent postoperative results and a significant improvement in patient's quality of life for a follow-up period of 1 year.     

Transabdominal preperitoneal versus totally extraperitoneal repair of inguinal hernia: a meta-analysis of randomized studies

Background

The aim of the present study was to comparatively evaluate the outcomes of laparoscopic transabdominal preperitoneal inguinal hernia repair and totally extraperitoneal repair.

Methods

The electronic databases of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a meta-analysis of randomized clinical trials was undertaken.

Results

Seven studies comprising 516 patients with 538 inguinal hernia defects were identified. A shorter recovery time (P = .02) was found for totally extraperitoneal repair in comparison with transabdominal preperitoneal inguinal hernia repair (weighted mean difference = −.29; 95% confidence interval [CI], −.71 to .07) although the length of hospitalization (P = .89) was similar in the 2 treatment arms (weighted mean difference = .01; 95% CI, −.13 to .15). Operative morbidity (P = .004) was higher for the preperitoneal approach (odds ratio = 2.15; 95% CI, 1.29 to 3.61). No differences were found with regard to the incidence of recurrence, long-term neuralgia, and operative time.

Conclusions

Current evidence suggests similar operative results for endoscopic and laparoscopic inguinal hernia repair, with a trend toward higher morbidity for the preperitoneal approach. Randomized trials with a longer-term follow-up are needed in order to assess the effect of each approach on the prevention of recurrence.     

Influence of the esophageal hiatus size on the lower esophageal sphincter, on reflux activity and on symptomatology

Hiatal hernia is an underlying factor contributing to gastroesophageal reflux disease (GERD). However, it remains elusive whether the size of the esophageal hiatus has a de facto influence on the lower esophageal sphincter (LES), on the intensity of patient reflux, on GERD symptoms and on the quality of life (QoL). One hundred patients with documented chronic GERD underwent laparoscopic fundoplication. QoL was evaluated before surgery using the Gastrointestinal Quality of Life Index (GIQLI). Additionally, GERD symptoms and nonspecific gastrointestinal symptoms were documented using a standardized questionnaire (score 0-224). The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Correlation analysis between the preoperative QoL, GERD symptoms, esophageal manometry, multichannel intraluminal impedance monitoring data and HSA size was performed, in order to investigate whether the HSA has an influence on the patients'symptoms, GIQLI, manometry and multichannel intraluminal impedance monitoring data. Statistical significance was set at a P-value of 0.05. The HSA sizes ranged from 1.51cm(2) to 16.09cm(2) (mean 4.14cm(2) ). The preoperative GIQLI ranged from 15 points to 133 points (mean 94.37 points). Symptom scores ranged from 2 points to 192 points (mean 49.84 points). No significant influence of the HSA on GIQLI or preoperative symptoms was recorded. HSA size had a significant negative effect on LES pressure. Additionally, there was a significant positive correlation between HSA size and number of refluxes in supine position. For the rest of the evaluated data, including DeMeester score, total number of refluxes, refluxes in upright position, acid reflux events, proximal reflux events, LES length and body motility, no significant correlation was found. Although patients subjectively are not significantly affected by the size of the hiatus, it has significant effects on the LES pressure and on gastroesopageal reflux in supine position.     

Meta-analysis of Laparoscopic Versus Open Repair of Perforated Peptic Ulcer

Background and Objectives:

Laparoscopic treatment of perforated peptic ulcer (PPU) has been introduced as an alternative procedure to open surgery. It has been postulated that the minimally invasive approach involves less operative stress and results in decreased morbidity and mortality.

Methods:

We conducted a meta-analysis of randomized trials to test this hypothesis. Medline, EMBASE, and the Cochrane Central Register of Randomized Trials databases were searched, with no date or language restrictions.

Results:

Our literature search identified 4 randomized trials, with a cumulative number of 289 patients, that compared the laparoscopic approach with open sutured repair of perforated ulcer. Analysis of outcomes did not favor either approach in terms of morbidity, mortality, and reoperation rate, although odds ratios seemed to consistently support the laparoscopic approach. Results did not determine the comparative efficiency and safety of laparoscopic or open approach for PPU.

Conclusion:

In view of an increased interest in the laparoscopic approach, further randomized trials are considered essential to determine the relative effectiveness of laparoscopic and open repair of PPU.     

Laparoscopic Revisional Fundoplication with Circular Hiatal Mesh Prosthesis: The Long-term Results

BACKGROUND: Failure of hiatal closure has proven to be the most frequent complication leading to revisional surgery after primary failed open or laparoscopic antireflux surgery. To prevent hiatal hernia recurrence some authors recommend the use of prosthetic meshes for reinforcement of the hiatal crura. The aim of the present prospective study was to evaluate the safety and effectiveness of a circular hiatal onlay mesh prosthesis applied during laparoscopic refundoplication after primary failed antireflux surgery with intrathoracic wrap migration. The follow-up period was 5 years. METHODS: A total of 33 patients underwent laparoscopic refundoplication for recurrent symptoms of gastroesophageal reflux disease after primary failed laparoscopic or open antireflux surgery. The underlying morphological complication for symptom recurrence in all patients was hiatal hernia recurrence with intrathoracic migration of the fundoplication. During revisional surgery, after breakdown of the former fundoplication, the esophageal hiatus was thoroughly revised and a circular polypropylene mesh was used to buttress the primarily simple sutured hiatal crura. Additionally, in all patients a refundoplication was performed. Recurrences, complications, functional data, esophagogastroduodenoscopy, and cinematographic X-ray results, as well as quality of life data, were evaluated for the 60-month follow-up period. RESULTS: All reoperations were successfully completed laparoscopically. Twenty-one patients underwent laparoscopic 360 degrees "floppy" Nissen refundoplication, and 12 patients underwent laparoscopic 270 degrees Toupet refundoplication. Hiatal closure was performed by placing a circular polypropylene sheet that had a 3-4 cm keyhole for the esophageal body. Of 24 patients who underwent redo-surgery before May 2000, no patient developed a recurrent hiatal hernia during the first 12 postoperative months. All 33 patients were re-evaluated and underwent complete diagnostic work-up over a follow-up period of 60 months postoperatively. During the long-term follow-up, a new recurrent hiatal hernia with intrathoracic wrap migration developed in 2 patients (6%). In both cases, slippage occurred anteriorly to the esophagus. Both patients were scheduled for repeat refundoplication. In all other patients no recurrence occurred for the complete follow-up period, and no mesh-related complications developed. CONCLUSIONS: Laparoscopic refundoplication for primary failed hiatal closure with the use of a circular mesh prosthesis is a safe and effective procedure to prevent hiatal hernia recurrence for short- and mid-term follow-up. However, for long-term follow-up, even with the placement of prosthetic mesh, re-recurrence occurs in some patients, leading to repeated surgery.     

Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery?

Background: Due to the widespread availability and acceptance of minimal-access surgery, laparoscopic antireflux surgery has become the standard procedure for the treatment of severe gastroesophageal reflux disease (GERD). However, open and laparoscopic antireflux procedures sometimes result in failure, so that redosurgery is required in some cases. The aim of this prospective study was to evaluate the surgical outcome and quality of life of patients who underwent refundoplication after the failure of primary open antireflux surgery. Methods: Twenty patients with a mean age of 52 years (range, 33–69) underwent laparoscopic refundoplication after primary open antireflux surgery. Four of them had undergone surgery twice previously. Preoperative and postoperative data, including esophageal manometry, 24-h pH monitoring, and assessment of quality of life, were reviewed prospectively. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). Results: In 18 patients (90%), the reoperation was completed successfully laparoscopically. Two others (10%) required conversion to an open procedure. One of them had an injury of the gastric wall; in the other case, severe bleeding of the spleen necessitated the conversion. The average operating time was 245 min. Preoperatively, the main symptoms were recurrent reflux in 14 cases and a combination of re-reflux and dysphagia in six cases. The anatomic findings were telescope phenomenon (n = 6), hiatal disruption (n = 10), and wrap breakdown (n = 4). Postoperatively, two patients suffered from dysphagia and required pneumatic dilatation. The lower esophageal sphincter (LES) pressure increased significantly from a preoperative value of 6.08 mmHg to 12.2 mmHg at 3 months and 11.9 mmHg at 1 year after surgery. The DeMeester score decreased from a preoperative value of 69.8 to 17.1 at 3 months and 14.6 at 1 year postoperatively. The GIQLI score increased from a preoperative value of 84.9 points to 119.6 points at 3 months and 120.1 points at 1 year. Conclusion: Laparoscopic refundoplication after the failure of a primary open intervention is an effective procedure that can be performed safely by experienced laparoscopic surgeon. The procedure yields excellent functional results and leads to significant improvement in the patient's quality of life.     

Austrian experiences with redo antireflux surgery

Background From 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results. Methods A questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms). Results Out of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach. Conclusion Laparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience. Preliminary results of this study were presented at the EAES Congress in Glasgow, 15–18 June 2003     

Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap

Background Postoperative dysphagia after laparoscopic antireflux surgery usually is transient and resolves within weeks after surgery. Persistent dysphagia develops in a small percentage of patients after surgery. There still is debate about whether postoperative dysphagia is caused by the type or placement of the fundic wrap or by mechanical obstruction of the hiatal crura. This study aimed to investigate patients who experienced recurrent or persistent dysphagia after laparoscopic antireflux surgery, and to identify the morphologic reason for this complication. Methods A sample of 50 patients consecutively referred to the authors’ unit with recurrent, persistent, or new-onset of dysphagia after laparoscopic antireflux surgery were prospectively reviewed to identify the morphologic cause of postoperative dysphagia. According to their radiologic findings, these patients were divided into three groups: patients with signs of obstruction at or above the gastroesophageal junction suspicious of crural stenosis (group A; n = 18), patients with signs of total or partial migration of the wrap intrathoracically (group B; n = 27), and patients in whom the hiatal closure was radiologically assessed to be correct with a supposed stenosis of the wrap (group C; n = 5). The exact diagnosis of a too tight (group A) or too loose (group B) hiatus in contrast to a too tight wrap (group C) was established during laparoscopic redo surgery (groups B and C) or by x-ray during pneumatic dilation (group A). Results For all 18 group A patients, intraoperative x-ray during pneumatic dilation showed the typical signs of hiatal tightness. Of these, 15 were free of symptoms after dilation, and 3 had to undergo laparoscopic redo surgery because of persistent dysphagia. In all these patients, the hiatal closure was narrowing the esophagus. All the group B patients underwent laparoscopic redo surgery because of intrathoracic wrap migration. Intraoperatively, all the patients had an intact fundoplication, which slipped above the diaphragm. Definitely, only in 10% of all 50 patients (group C) presenting with the symptom of dysphagia, was the morphologic reason for the obstruction a problem of the fundic wrap. Conclusions In most patients, postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap. Poster presentation at the 45th annual meeting of the Society for Surgery of the Alimentary Tract (SSAT), Digestive Disease Week (DDW), New Orleans, Louisiana, 15–19 May, 2004