Gastrectomy as a Remedial Operation for Failed Fundoplication

Abstract

The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997-2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients' overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty.

The role of short-limb Roux-en-Y reconstruction for failed antireflux surgery: a single-center 5-year experience

“…The newly created fundoplication may replicate the original configuration (if the previous failure was purely technical) or may involve a variation (i.e., partial fundoplication, should esophageal dysmotility coexist). Diversion of the main part of the stomach in the form of RNY reconstruction (GJ or EJ) is a recognized alternative strategy, and may be considered when a new fundoplication is not technically feasible or is expected to produce suboptimal results [15,[19][20][21]. In certain situations, esophagectomy is the only option for end-stage esophageal disease [27].…”

“…Good outcomes have been reported [18][19][20][21]. Previously, we presented our initial experience with RNY reconstruction for failed fundoplication with at least 1-year follow-up [22].…”

Perioperative outcomes of surgical procedures for symptomatic fundoplication failure: a retrospective case–control study

“…Major and/or minor complications occurred in 32% of patients without mortality in this difficult group of patients in whom reoperative fundoplication had a high likelihood of failure. A retrospective comparison between reoperative fundoplication and gastrectomy with Roux-en-Y reconstruction for failed fundoplication revealed that despite having more severe endoscopic complications of GERD and more previous fundoplications, the gastrectomy group experienced greater relief of their primary symptom [26]. In-hospital morbidity, however, was higher following gastrectomy.…”

Outcomes of surgical management of symptomatic large recurrent hiatus hernia

“…We have previously reported less than satisfactory outcomes in patients undergoing redo Collis fundoplication, especially in presence of decreased esophageal motility [18]. We have increasingly and successfully employed RNY reconstruction in a larger number of reoperative procedures [19][20][21]. This study clearly shows that patients with short esophagus and large recurrent hiatus hernia report significantly better results with RNY reconstruction compared with redo Collis gastroplasty.…”