Presentation from a postgraduate course for the 2011 meeting of the Society for Surgery on the Alimentary Tract Annual Meeting.

1. Conflict of Interest /
Disclosure
• No financial or other relationship with
any product or treatment discussed in
this talk
1

2. Redo Anti-reflux Surgery:
When and How
SSAT Meet The Professor Luncheons
May 9, 2011
Chicago, Illinois
C. Daniel Smith
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3. ARS & PEH – Failure Happens
• Anti-reflux Surgery Failure
- 5-40%
- Redo vs. back on PPIs
• PEH Failure
- 25-40%
- ? anatomic vs. clinical failure
3

4. Failed ARS & PEH – Management Challenging
• What is failure?
• How to work-up?
• Decision about redo
• Intraoperative
- Technically demanding
- What to do (e.g., take down wrap, mesh, full wrap)
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5. Redo ARS and PEH – Success is Possible
307 redo fundoplications 1,892
1 fundo internal
0
in 285 patients 187
1 fundo external
0
54 fail (2.8%)
1st redo fundoplication
241
42
1 redo external
st
17 fail (7.1%)
2nd redo fundoplication
59
2
2 redo external
st 4 fail (6.8%)
3rd redo fundoplication
6
1 fails (17%)
4th redo fundoplication
1
5

6. 6

7. 1,892
10 fundo internal
• Fundoplication failure
54 fail (2.8%) (reoperation) is unusual in
1st redo fundoplication experienced hands
241
17 fail (7.1%)
• Redo fundoplication can be
2nd redo fundoplication done safely with the majority
59
of patients improved
4 fail (6.8%)
3rd redo fundoplication
6
• Herniation of the fundus
remains problematic - new
1 fails (17%)
strategies for management
4th redo fundoplication
1
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8. Failed ARS & PEH – Keys to Success
• Know patterns of failure
• Diagnostic work-up
• Patient selection
• Intraoperative management
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9. ARS & PEH – Patterns of Failure
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10. ARS & PEH – Patterns of Failure
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11. ARS & PEH – Patterns of Failure
• It all starts here
• Pattern of failure determines indication
for surgery
• Correlate symptoms & diagnostics to
pattern of failure
• Strong correlation predicts success
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12. ARS & PEH – Patterns of Failure
Undone Wrap Tight Wrap / Crura
Heartburn Heartburn
Chest Pain Chest Pain
Regurgitation Regurgitation
Dysphagia Dysphagia
Nausea Nausea
Bloating Bloating
SOB SOB
Aspiration Aspiration
Slip / Misplaced Wrap Hiatal Hernia
Heartburn Heartburn
Chest Pain Chest Pain
Regurgitation Regurgitation
Dysphagia Dysphagia
Nausea Nausea
Bloating Bloating
SOB SOB
Aspiration Aspiration
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13. ARS & PEH – Patterns of Failure
13

14. Prior Antireflux /
PEH Surgery
EGD
BaSw
Anatomically Obvious Anatomic
Normal Problem
pH
EMS
Patterns
GES Symptom
of
Correlatio Failure
n
No GERD Confirm GERD EMS
GES
Entertain Other
Diagnosis Redo Antireflux +/-
G-tube
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15. Failed ARS & PEH – Work-up
• Read your own contrast GI studies
• See endoscopy directly (do
endoscopy yourself or go to GI
unit)
• No one better that you to recognize
and correlate failure patterns
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16. Redo ARS & PEH – Patient Selection
Not everyone with failure should have a redo
Presentation Redo?
65 yo male, 6 years of good
response, now with recurrent HB Easy Yes
and hiatal hernia with wrap undone
32 yo female, never completely
better after wrap, “loose wrap”, pH No
slightly increased
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17. Two Predictors of Outcome
Patient Selection
Operative Technique
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18. Redo ARS & PEH – Operative Management
• Start on left
• Enter mediastinum from left & posterior
• Open gastrohepatic well away from hiatus –
“cheater plane” over caudate
• Always take down prior wrap unless its your
own and immediate hiatal herniation
• Consider PEG if difficult dissection / large
hernia
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19. Redo ARS & PEH – Summary
• Failure happens
• Become an expert diagnostician
• Correlate symptoms & diagnositics to
pattern of failure – beware no correlation
• Technical execution in OR critical
• Get help
• Good outcomes are possible
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20. Redo ARS – Case 1
Presentation
3 yr ago LPH/N – GERD & Chest pain
Never better postop
6 wks postop unable to swallow more than liquids
Now with persistent chest pain dysphagia
Lost 30 pounds
Op findings
Long tight wrap
Wrap on proximal stomach
Suture tethering proximal stomach to right crus
No diverticulum
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21. Redo ARS – Case 2
Presentation
LN 6 year ago – GERD
Better for 4 years
Now with progressive dysphagia, CP, GERD
Eating makes things worse, GERD at night
No bloating
Op findings
Slipped wrap now around gastric body
Proximal stomach in chest
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