Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication

Transcription

1 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2013;11: Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication JOEL E. RICHTER Division of Digestive Diseases and Nutrition, Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, Florida This article has an accompanying continuing medical education activity on page e39. Learning Objective At the end of this activity, the successful learner will be able to identify and treat the common complications and side effects after antireflux therapy. Podcast interview: Also available on itunes. Even skilled surgeons will have complications after antireflux surgery. Fortunately, the mortality is low (<1%) with laparoscopic surgery, immediate postoperative morbidity is uncommon (5% 20%), and conversion to an open operation is <2.5%. Common late postoperative complications include gas-bloat syndrome (up to 85%), dysphagia (10% 50%), diarrhea (18% 33%), and recurrent heartburn (10% 62%). Most of these complications improve during the 3 6 months after surgery. Dietary modifications, pharmacologic therapies, and esophageal dilation may be helpful. Failures after antireflux surgery usually occur within the first 2 years after the initial operation. They fall into 5 patterns: herniation of the fundoplication into the chest, slipped fundoplication, tight fundoplication, paraesophageal hernia, and malposition of the fundoplication. Reoperation rates range from 0% 15% and should be performed by experienced foregut surgeons. Keywords: Anti-reflux Surgery; GERD. In the past 15 years there has been an increase in the number of antireflux operations being performed. The reasons include the development and proliferation of laparoscopic techniques, the increase in the fraction of the population that is overweight, which worsens their gastroesophageal reflux disease (GERD), and possibly the increased willingness of the population to undergo an operation to avoid the necessity of lifetime medications or lifestyle changes. The operation is now widely available in community hospitals, the length of stay ranges between 1 and 4 days, some operations are even performed as day surgery, and most patients return to normal activity within 2 weeks. 1,2 Similar to younger patients, reflux patients older than 65 years of age can expect an excellent outcome in at least 90% of cases after laparoscopic surgery. 3 On the basis of the U.S. Nationwide Inpatient Sample, there were 9173 adult antireflux operations in 1993, which has increased nearly 3.5-fold, reaching a peak at 32,980 in For poorly understood reasons, the most recent available data for 2006 show a 40% decline to 19,688 operations. 5 This article will focus on the surgical and medical complications commonly reported after laparoscopic antireflux surgery (Table 1). The available reports on this subject are numerous, so I have relied on summary data available from the Society of American Gastrointestinal and Endoscopic Surgeons 1 and the Agency for Healthcare Research and Quality Effective Health Care Program Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease: An Update to the 2005 Report. 6 The review will summarize mortality and morbidity data for laparoscopic antireflux operations, review the common perioperative and postoperative complications, and discuss the common reasons for fundoplication failures. General Mortality, Morbidity, and Conversion Rate to Open Operation By all measures, laparoscopic antireflux surgery is a safe operation when performed by experienced surgeons. Postoperative 30-day mortality is rare, and among available reports it is usually 1%. 1 By using the U.S. Nationwide Inpatient Sample (20% stratified sample of U.S. nonfederal hospitals recording 5 8 million hospital stays from about 1000 hospitals each year), we reported the inpatient mortality after antireflux surgery decreased from 0.82% in 1993 to 0.26% in 2000, but it increased to 0.54% by The latter increase in mortality was associated with the patients being older and having a longer length of hospital stay and more complications. A review of the Department of Veterans Affairs administrative databases from identified 3145 patients undergoing antireflux surgery. 7 Of this group, 28 patients died, a mortality rate of 0.8%. The major causes of death were gastrointestinal hemorrhage, necrosis of the stomach, perforation of the esophagus or stomach, cardiac arrest, respiratory complications, and pulmonary embolism. The perioperative and immediate postoperative morbidity rate of laparoscopic antireflux surgery varies widely related to Abbreviations used in this paper: GERD, gastroesophageal reflux disease; PPI, proton pump inhibitor by the AGA Institute /$

2 466 JOEL E. RICHTER CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 11, No. 5 Table 1. Prevalence of Medical and Surgical Complications of Antireflux Surgery Mortality ( 30 days) 1% or less Perioperative and immediate postoperative morbidity 8% 17% Open conversion rate 0% 24% Early postoperative complications Bowel perforation 0% 4% Bleeding and splenic injury 1% Pneumothorax 0% 10% Severe postoperative nausea and vomiting 2% 5% Late postoperative complications Gas-bloat syndrome 1% 85% Dysphagia Early 10% 50% Late 3% 24% Diarrhea 18% 33% Recurrent heartburn 10% 62% Need for revisional surgery Laparoscopic Nissen fundoplication 0% 15% Laparoscopic Toupet fundoplication 4% 10% experience, technique, and degree of follow-up. One recent review suggested a rate up to 17%. 8 Our National Inpatient Sample database found that 8.3% of adults hospitalized for antireflux surgery had at least 1 complication in This rate decreased to 4.7% in 2000 but increased to 6.1% in In these reviews and reports, the most important complications include perforation, hemorrhage, splenic injury, pneumothorax, and wrap herniation into the chest from intractable nausea and vomiting. The rate of open conversion during laparoscopic antireflux surgery ranges from 0% 24%; however, most series from highvolume centers report conversion rates 2.4%. 1 The intraoperative conversion rate parallels the surgeons experience and the operative volume in the hospital. 9,10 The cause for conversion may be loosely divided into 3 categories: (1) complications, (2) surgeon comfort (ie, directed choice), and (3) equipment failure. 11 Surgeon comfort is a broad category that encompasses such problems as adhesions from previous operations, difficult exposure caused by a large liver, or failure to progress. In addition, the category boundaries are indistinct because surgeon comfort plays a variable role in the decision to convert after most complications or equipment failures. The distribution among categories in one review representing 135 open conversions was 34.1% complications, 59.3% surgeon comfort, and 6.7% equipment failure. 11 Acute Perioperative and Immediate Postoperative Complications Poor functional outcome after antireflux surgery usually can be traced to inadequate patient selection or technical problems encountered during the operation. In other cases, a different set of complications become manifest clearly during the operation or immediately postoperatively and potentially can lead to significant morbidity if not immediately recognized and treated. 12 Gastrointestinal Visceral Perforation Bowel perforation, especially of the esophagus and stomach, can be life-threatening and lead to longer hospital stay. The perforation rate reported in the literature varies according to technique and exposure, ranging from 0% 4%, 1 with the highest incidences being reported with redo fundoplications. 13 Injury may occur during placement of the camera port with a trocar, from excessive retraction on the stomach, passage of the esophageal bougie, or during lysis of adhesions. 12 Because it is not possible to palpate a bougie or nasogastric tube during laparoscopy, correction of the esophagogastric angulation by appropriate traction on the stomach is critical to avoid damage during bougie passage. The importance of experience in passing the tube or dilator is also important 8 ; this should be done by an experienced anesthesiologist or surgeon. The frequency of perforation during laparoscopic operation is no higher than the conventional open approach of laparotomy. 8 The greatest threat to the patient is unrecognized damage to the esophagus or stomach, which can be at least partly prevented by frequent leakage testing during the operation. If the perforation is recognized and repaired during the index operation, the patient s subsequent course is usually uneventful, and the functional results are excellent. 14 Bleeding and Splenic Injury Usually the bleeding encountered during antireflux surgery is minor and easily controlled. Most commonly, bleeding occurs during division of the short gastric vessels, which is necessary to mobilize the fundus of the stomach. 12 This technique generally includes dissecting and cutting the short gastric vessels arising from the spleen. Bleeding and tears of the splenic capsule were common after the open laparotomy and fundoplication, requiring splenectomy in 5% 11% of cases; however, the rate has decreased to 1% after laparoscopic procedures. 10 This decrease in morbidity is due to better exposure of the abdominal organs induced by the pneumoperitoneum and improvements in laparoscopic techniques (ie, ultrasonic shears that coagulate blood vessels as they divide tissue), facilitating division of the short gastric vessels with less trauma to the spleen. Not unexpectedly, patients in whom accidental splenectomy has to be carried out have an increased rate of infection complications as well as a slight but definite increased postoperative mortality rate. 15 Pneumothorax During mediastinal dissection, it is not uncommon to create a tear of one or both pleura. Rates of pneumothorax during laparoscopic antireflux surgery in most series range from 0% 1.5% but may be as high as 10% especially in repairing paraesophageal hernias. 1 Postoperative Nausea and Vomiting This can be a major problem after laparoscopic antireflux surgery, causing both patient discomfort and harm to the newly created fundoplication. Up to 60% of patients have severe postoperative nausea, with as many as 5% experiencing vomiting in the recovery unit or hospital room after laparoscopic fundoplication. 16 Routine prophylactic treatment with intravenous antiemetics such as ondansetron is recommended. 17 Patients who retch or vomit in the early postoperative period are at risk of disrupting the crural closure and/or intrathoracic herniation of the fundoplication. Patients with early postoperative vomiting should undergo immediate barium esophagogram to access the integrity of the fundoplication. If a disrup-

3 May 2013 COMPLICATIONS AFTER ANTIREFLUX SURGERY 467 tion is identified, the patient should be taken back to surgery as early as possible. If reoperation is performed within 4 10 days, the procedure is usually relatively simple, but if it is delayed until adhesions develop, the anatomy may be difficult to discern and manage. 17 Late Postoperative Complications Gas-bloat Syndrome The gas-bloat syndrome comprises an ill-defined and variable group of complaints assumed to result from the inability to vent gas from the stomach into the esophagus after fundoplication. The predominant complaint is bloating, but other symptoms include abdominal distention, early satiety, nausea, upper abdominal pain, flatulence, inability to belch, and inability to vomit. The cause of the syndrome is unclear, but proposed mechanisms include (1) inability of the surgically altered gastroesophageal junction to relax in response to gastric distention; (2) aerophagia, a frequent habit among patients with severe GERD, which becomes problematic after fundoplication when the air cannot be vented; (3) impairment of mealinduced receptive relaxation and accommodation of the stomach with rapid gastric emptying; and (4) surgical injury to the vagus nerve, which delays gastric emptying and interferes with transient relaxation that is part of the normal belch reflux. 18 The reported frequency of gas-bloat syndrome has ranged widely from 1% 85%, depending on the definition of the disorder as well as underlying population and type of fundoplication. 6 For example, an early Veterans Affairs Hospital trial of medication and surgical therapies for GERD found by questionnaire that 81% of the surgical patients had at least 1 symptom of the gas-bloat syndrome, but the comparable medically treated patients also had a 60% rate of gas-bloat symptoms. 19 These symptoms seem to be worse with a total compared with a partial fundoplication. 8 Symptoms are worse immediately after surgery, with most improving or resolving during the first year. Recommended therapies, albeit without convincing evidence of effectiveness, include (1) dietary modifications to avoid gasproducing foods and carbonated beverages, (2) eating slower to avoid aerophagia, (3) cessation of smoking, (4) gas-reducing agents such as simethicone, and (5) prokinetic drugs. Biofeedback mechanisms have been used to retrain patients to decrease the frequency of swallowing after antireflux surgery with some success. 20 Debilitating cases need further evaluation for small bowel obstruction caused by adhesions from the original surgery and delayed gastric emptying. Up to 40% of patients with GERD may have some element of delayed gastric emptying, 21 but antireflux surgery usually accelerates the emptying of both solids and liquids. 22 Inadvertent vagotomy, especially common with redo fundoplications, can delay gastric emptying of solids by interfering with antral motility and pyloric relaxation. Severe cases may require surgical revision including conversion to a partial fundoplication, allowing easier gas venting, or pyloromyotomy when delayed gastric emptying is documented. 23 Dysphagia. Some degree of dysphagia, especially for solid foods, is expected in all patients for the first 2 6 weeks after surgery. These complaints are presumably a consequence of postsurgical edema and inflammation slowing bolus transit of foods. 6 Marked dysphagia for liquids is rare and should suggest an important anatomic dysfunction. These patients are initially treated with dietary modification (soft diets, plenty of fluids) and reassurance, with the dysphagia usually resolving spontaneously within 2 3 months. However, 3% 24% of patients experience dysphagia that persists beyond 3 months that requires more than dietary management. 24 This latter group of patients usually have a fundoplication that is too tight for their functional esophageal pump, but other causative problems include previously unrecognized achalasia, healed peptic stricture, paraesophageal hernia, excessively tight crural closure, slipped fundoplication into the chest with a recurrent hernia, or distal migration of the wrap onto the stomach that creates a twocompartment stomach. Preoperative manometry is mandatory to exclude achalasia, but esophageal function testing otherwise is poor in defining those patients likely to be troubled with postoperative dysphagia. 25 Therefore, tailoring the type of fundoplication to the esophageal pump has lost favor, with the exception of a partial fundoplication in patients with aperistalsis. 26 Patients with dysphagia before surgery are more likely to have dysphagia after surgery, regardless of the type of fundoplication. 27 Patients with persistent dysphagia need further investigation to determine whether the fundoplication is too tight or long vs an anatomic displacement. These tests include barium esophagogram with a 13-mm tablet, esophageal manometry, and/or endoscopy. If the fundoplication is intact, bougie and/or through-the-scope balloon dilation will relieve symptoms in one-half to two-thirds of cases, usually with one series of dilations up to 18 mm (54F). 24,28 This can be done within a month of the fundoplication and does not produce new reflux symptoms. 24 More recently, pneumatic dilation (30 to 40-mm balloons) has been advocated, if the patients fail to respond to bougie dilation and the nadir lower esophageal sphincter pressure on manometry is 10 mm. 29 About two-thirds of patients not responding to bougie dilation with tight fundoplications will respond to pneumatic dilation. The remainder will need revision surgery that converts the complete fundoplication to a partial wrap. On the other hand, patients with slipped fundoplications or paraesophageal hernias usually will require reoperation because less than 30% respond to bougie dilation alone. 24 Diarrhea and flatulence. Diarrhea is a frequent complication of fundoplication that is often not discussed before surgery. In a study of 84 patients responding to a telephone survey after antireflux surgery, 15 (18%) described the new onset of diarrhea. 30 The diarrhea usually developed within 6 weeks of the operation and was mild and low volume (2 4 bowel movements/day) and worse after meals. In 4 patients it was associated with fecal incontinence. In this study, only 2 of 15 patients (13%) had complete resolution of their diarrhea after 2 years. Other reports describe rates as high as 33%, but these studies do not describe whether the diarrhea was present before surgery. 31 The cause of post-fundoplication diarrhea is not known. Proposed mechanisms include (1) rapid gastric emptying from the fundoplication overloading the small intestine s ability to handle the osmotic bolus, the dumping syndrome, (2) vagal injury with subsequent small bowel overgrowth, and (3) exacerbation of underlying irritable bowel syndrome. 30 Antimotility agents including codeine, antibiotics for small bowel overgrowth, and cholestyramine may ease the diarrhea, but the management is empirical.

4 468 JOEL E. RICHTER CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 11, No. 5 Flatulence has been reported in 12% 88% of patients after antireflux surgery. 31,32 This increase in flatulence is attributable to the patients inability to belch and subsequent passage of more gas into and then through the gastrointestinal tract. 32 As with the gas-bloat syndrome, the true risk after surgery is unknown, because many studies only surveyed patients after surgery and asked them to recall how they were before the surgery (recall bias). Recurrent heartburn. The durability of antireflux surgery has recently been the topic of much interest and evolving observational research. This was spurred by the 10-year follow-up of a large randomized Veterans Affairs Hospital trial of medical vs surgical therapy performed in the mid-1980s. 33 Among the medically treated patients, 92% were still on medications, whereas surprisingly 62% of the patients undergoing surgical fundoplication were back on reflux medications (50% proton pump inhibitors [PPIs], 50% histamine-2 receptor antagonists). Furthermore, 16% of the surgical patients had at least 1 additional reflux operation. In a large Veterans Affairs administrative database review of 3145 patients undergoing surgery from with at least 4.5 years of follow-up, antacid prescriptions were dispensed regularly including histamine-2 receptor antagonists (23.8%), PPIs (34.3%), and prokinetic drugs (9.2%). Overall, nearly 50% of patients received at least 3 prescriptions for one of these drugs. 34 Other surgical centers of excellence studies suggest postoperative rates of use of acid-reducing medications of 20%. 1 Does the fact that the patient is back on PPIs prove that surgery has failed? This can only be accurately assessed with postoperative ph testing in symptomatic patients. Two studies have adequately addressed this issue, with similar findings. Lord et al 35 identified 37 patients (43%) who were taking acid suppression medications after fundoplication. However, only 24% (9 of 37) had abnormal 24-hour ph testing. Recurrent heartburn and regurgitation were the only symptoms associated with abnormal ph results. Likewise, Wijnhoven et al 36 identified by postal survey 312 patients (37%) who were taking PPIs an average of 6 years after fundoplication. Postoperative ph studies were abnormal in 16 of 61 patients (26%) on medication and in 5 of 78 patients (6%) not taking medication. Although small studies, these results suggest many patients may be back on medications, not for recurrent acid reflux but for nonspecific peptic symptoms such as dyspepsia or extraesophageal complaints, or they have other reasons for antacid therapy such as peptic ulcer disease. An empirical trial of PPIs is reasonable with recurrent reflux symptoms after fundoplication, but the requirement for progressively higher doses of PPIs or possible revision surgery requires documentation that the patient actually has recurrent pathologic acid reflux. Recurrent atypical symptoms. This is a particularly common and important problem. Whereas well-documented heartburn and regurgitation tend to respond to medicine or surgery in 85% 95% of patients, 1,6 pulmonary, ear, nose, and throat, and chest pain, the so-called atypical symptoms of GERD, are less likely to respond to either type of therapy. 37 For example, So et al 38 observed that among 115 patients undergoing laparoscopic fundoplication, 93% had relief of their heartburn, whereas only 56% of 35 patients had relief of atypical symptoms. The response rates for laryngeal, pulmonary, and chest pain symptoms were 78%, 58%, and 48%, respectively. These results are even more disappointing when patients are separated into atypical throat symptoms with classic reflux symptoms or atypical symptom alone. In a recent series, Ratnasingam et al 39 observed that 76% of 61 patients with both typical and atypical reflux symptoms improved after antireflux surgery, whereas only 47% of 23 patients with isolated atypical reflux symptoms had similar improvements after antireflux surgery. The reasons for these discordant results are poorly understood but are consistent across the literature and independent of surgical skills. Contributing factors include (1) poor understanding of the pathophysiology of these symptoms and relationship to GERD, (2) lack of reliable tests to document GERD as the causal factor for atypical symptoms, (3) poor response of atypical symptoms to even high-dose PPI therapy, and most importantly, (4) the multiple etiologies contributing to these complaints, which often overlap in the same patient. 37 The best predictors of a favorable surgical outcome are the presence of typical heartburn and/or regurgitation, markedly abnormal acid reflux testing (% time ph 4 more than 12%), and prior improvement of atypical symptoms on PPIs. 38,40 Patients with atypical symptoms not meeting these criteria should be counseled that fundoplication has a high risk of symptomatic failure, surgical side effects may be more common, and alternative explanations for their symptoms should be aggressively pursued. 41 Revisional Antireflux Surgery Although long-term results with antireflux surgery are generally good, especially if performed by experienced surgeons, failures are unavoidable. Most failures occur within the first 2 years of the initial operation. 1 In large reviews, the most common symptoms are recurrent heartburn and/or dysphagia, with pain and bloating being less common. 10,42 Figure 1 illustrates several of the primary patterns of fundoplication failures. 43 Herniation of the fundoplication into the chest (type 1A) is the most common failure reported in 30% 80% of cases. 10,42,43 These failures usually result from disruption of the crural repair or failure to perform the initial wrap over a tension-free segment of intra-abdominal esophagus. To avoid these failures, there must be at least 2 3 cm of tension-free intra-abdominal esophagus below the hiatus, and the gastroesophageal junction must be clearly identified. A slipped Nissen fundoplication occurs when part of the stomach lies both above and below the wrap (type 1B). This defect, accounting for 15% 30% of failures, 10,42,43 may arise from the stomach slipping through the fundoplication or incorrect positioning of the wrap around the stomach at the time of the original operation. Type II failures present as a posterior paraesophageal hernia and accounted for 23% of redo operations in one series. 43 The mechanism is thought to include inadequate hiatal closure or a redundant wrap, with some excess portion of the wrap serving as a lead point in the formation of the hernia. This can be prevented by the shoe-shine maneuver that ensures the wrap is not twisted or redundant and positioned appropriately on the distal esophagus. Type III failure occurs as a consequence of malposition of the wrap at the initial operation, accounting for about 10% of failures. 10,43 These patients often present with abdominal pain and worsening regurgitation as a result of their two-compartment stomach. A tight fundoplication represents an anatomically appropriately placed wrap that generates too much resistance for the

5 May 2013 COMPLICATIONS AFTER ANTIREFLUX SURGERY 469 Figure 1. Common patterns of primary fundoplication failures. Type 1 failures occur with displacement of gastroesophageal junction into the chest through the esophageal hiatus. Type 1A has herniation of both the wrap and gastroesophageal junction into the chest. Type 1B presents with recurrence of the hiatal hernia, but the wrap remains below the diaphragm. Type II failures are defined as failures caused by paraesophageal hernia. Type III failures occur as a consequence of malposition of the wrap at the time of initial surgery, usually on the cardia of the stomach. From Hatch KF, Daily MF, Christensen BJ, et al. Failed fundoplications. Am J Surg 2004;188: with permission. 43 esophageal pump. The primary complaint is dysphagia rather than heartburn. Studies suggest this may account for 8% 16% of redo operations. 10,42 Careful preoperative manometry to recognize a weak esophageal pump, performance of the fundoplication over a large bougie (52F 56F), or a floppy Nissen fundoplication or partial wrap may minimize this problem. 12 Other factors associated with recurrent symptoms include a fundoplication that is too loose, vagal injury, excessively tight crural closure, and pseudoachalasia. 12 Interestingly, complete fundoplication disruptions are much less common (3% 14%) in the laparoscopic era than with open operations ( 30%). 42 The keys to success for a redo fundoplication are (1) careful review of the patient s prior work-up and repeat studies as necessary, (2) recognition of esophageal shortening, and (3) complete takedown of the original fundoplication. 12 Although controversial, it is hypothesized that long-

6 470 JOEL E. RICHTER CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 11, No. 5 Table 2. Potential Pitfalls and How to Avoid Antireflux surgery is never an emergency procedure. All patients should be carefully evaluated before surgery. At a minimum, preoperative testing should include upper endoscopy, esophageal manometry, and ph testing (the latter primarily in patients with nonerosive GERD). Do not take short cuts. Even skilled foregut surgeons will have complications after antireflux surgery. All patients should have a frank discussion with their gastroenterologist and surgeon about potential postoperative problems including dysphagia, gas-bloat, diarrhea, and the durability of the operation with return of heartburn or atypical reflux symptoms. Treat these common complications with conservative therapy and never rush into redoing antireflux surgery. Most problems will improve during a period of 3 6 months. The revision of a fundoplication operation requires a very experienced foregut surgeon. The keys to success must not be violated. These include (1) careful review of the patient s prior work-up and repeat studies as necessary, (2) recognition of esophageal shortening, and (3) complete takedown of the original fundoplication. standing reflux leads to circumferential esophageal scarring and, in more severe cases, varying degrees of longitudinal scarring and esophageal shortening. A short esophagus should be suspected in the presence of a moderate or large nonreducible hiatal hernia, difficult to manage peptic stricture, or long-segment Barrett s esophagus. 44 Adequate laparoscopic mobilization of the mediastinal esophagus is critical in constructing a tension-free intra-abdominal fundoplication. If esophageal shortening is identified and adequate intra-abdominal esophageal length cannot be obtained, a Collis gastroplasty will be required. 45 The most important principle during reoperation is to restore normal anatomy before recreating the fundoplication. 12 This requires the wrap be completely taken down, the fundus restored to its normal location, and the degree of esophageal shortening determined. The restoration can be tedious, and it is very tempting to convert the Nissen fundoplication to what appears to the surgeon to be a posterior wrap. Taking this shortcut only increases the likelihood that the patient will not benefit from the reoperation. Dysphagia is often the result of an improperly constructed wrap, and to relieve this symptom, the fundoplication must be completely dismantled. Revisions of fundoplications must be done by experienced foregut surgeons. 1 In these settings, laparoscopic approaches to reoperative antireflux surgery offer similar results to open surgery, but conversion rates are higher than with the initial operation. 1 Reoperation rates range from 0% 15% for laparoscopic Nissen fundoplication and 4% 10% for laparoscopic Toupet fundoplication. 6 Compared with primary repair, redo surgery requires longer operation times and has higher complication rates (20% 45%), and the mortality rates are higher, from 0% 17%. 1,6 Finally, the likelihood of success for controlling GERD decreases with subsequent reoperations, approaching at least 10% per each revisional surgery and being no better than 50% or less in patients undergoing 3 or more reoperations. 46 For these latter unusual cases, serious consideration should be given to an esophagectomy. Conclusions The success of antireflux surgery requires disciplined cooperation between the gastroenterologist and surgeon to avoid potential pitfalls (Table 2). The gastroenterologist must select the appropriate patients on the basis of careful and thorough esophageal function testing. The surgeon must be skilled in the technical nuances of laparoscopic surgery and not reluctant to convert to an open laparotomy when problems occur. Nevertheless, complications occur after antireflux surgery. The perioperative/immediate postoperative complications are infrequent but can lead to rare fatalities. Late postoperative complications are much more common, but most resolve during 3 6 months after surgery. True failures after antireflux surgery are uncommon, usually occurring within the first 2 years after the initial operation. Reoperation rates range from 0% 15%, are associated with higher complications and mortality outcomes, and must be performed by experienced foregut surgeons. References 1. Stefanidis D, Hope WW, Kohn GP, et al. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc 2010;24: Jensen CD, Gilliam AD, Horgan LF, et al. Day-care laparoscopic Nissen fundoplication. Surg Endosc 2009;23: Pizza F, Rossetti G, Limongelli P, et al. Influence of age on outcome of total laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol 2007;13: Finks JF, Wei Y, Birkmeyer JD. The rise and fall of antireflux surgery in the United States. Surg Endosc 2006;20: Wang YR, Dempsey DT, Richter JE. Trends and perioperative outcomes of inpatient antireflux surgery in the United States, Dis Esophagus 2011;24: Agency for Healthcare Research and Quality the Effective Healthcare Program. Comparative effectiveness of management strategies for gastroesophageal reflux disease: an update to the 2005 report Washington, DC: Agency for Healthcare Research and Quality, Dominitz JA, Dire CA, Billingsley KG, et al. 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