Results of surgical treatment for recurrent postoperative gastroesophageal reflux

Abstract

The rate of recurrence of reflux esophagitis after classic antireflux surgery (fundoplication) is 10-15%. This rate is different in patients with esophagitis with and without Barrett's esophagus. We evaluated the clinical and laboratory findings in 104 patients with postoperative recurrent reflux esophagitis, determining the results of repeat antireflux surgery or an acid suppression-bile diversion procedure. Repeat fundoplication was performed in 26 patients, and truncal vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy in 78 patients. Esophagectomy as a third operation was performed in seven patients. After repeat antireflux surgery, endoscopic evaluation demonstrated improvement of esophagitis in a small proportion of patients. Barrett's esophagus remained unchanged, and no regression of ulcer or stricture was observed. These complications improved significantly after acid suppression-bile diversion surgery. Incompetent lower esophageal sphincter (LES) was present in 55.8% after initial surgery and in 23% after reoperation. Acid reflux, initially present in 94.6% of patients, was also observed in 93.6% after fundoplication, 68.8% after redo fundoplication, and 16.6% after treatment with the acid suppression-bile diversion technique. A positive Bilitec test was present in 78% of patients before the operation and 56.6% after the repeat operation, and was negative after bile diversion surgery. Among 13 patients (50%) submitted to repeat surgery alone, esophagectomy as a third operation was necessary as a result of severe non-dilatable stricture in seven patients. Our conclusions are that repeat antireflux surgery alone failed to improve Barrett's esophagus complications and that the best results were obtained in patients submitted to acid suppression-bile diversion surgery.

Complications and frequency of redo antireflux surgery in Denmark: a nationwide study, 1997–2005

“…Most of the Years after primary fundoplication redo operations were performed within the first one to four years after PF. Considering that there usually is a latency time of one to three years after symptomatic relapse [5,7,11], our data confirm that the majority of patients who relapsed after PF did so within the first two years (Fig. 1).…”

Surgical Reintervention After Failed Antireflux Surgery: A Systematic Review of the Literature

“…Eventually, 81 articles were eligible for inclusion in this study. According to the Oxford Centre for Evidence Based Medicine Levels of Evidence, 27 studies had a level of evidence IIb (33.3%)8, 10–35, two level of evidence IIIb (2.5%)36, 37, and 15 level of evidence IV (18.5%)38–52. The remaining 37 studies (45.7%) were cohort studies, but a level of evidence could not be adjudged owing to unknown study design53–89.…”

“…In 1,435 reoperations (31.3%), the indication for reoperation was not reported. Preoperative symptoms were assessed by questionnaire in 26 studies (32.1%) 10,14,17,18,23–25,28,30,33,36,45,53,54,56,61–66,71,74,76,87,88. In most studies (93.8%), preoperative workup consisted of esophagogastroduodenoscopy, barium swallow, and/or esophageal pH monitoring 10–28,30–41,43–46,48–76,78,79,81–89…”

“…The reasons to perform esophageal resection were severe esophagitis with or without Barrett metaplasia,15,25,59 peptic stricture of the esophagus,10,33,51,57,72,81 severely disturbed esophageal motility,26,44,57,81 or short esophagus 70,82. In 202 reoperations (4.4%), gastric resection was performed.…”

“…In 202 reoperations (4.4%), gastric resection was performed. Indications for this were alkaline reflux,10 dense adhesions on attempted refundoplication,33,59,86 or severe gastric paresis 25,81…”