Reoperative Antireflux Surgery for Failed Fundoplication: An Analysis of Outcomes in 275 Patients

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1 Reoperative Antireflux Surgery for Failed Fundoplication: An Analysis of Outcomes in 275 Patients Omar Awais, DO, James D. Luketich, MD, Matthew J. Schuchert, MD, Christopher R. Morse, MD, Jonathan Wilson, BS, William E. Gooding, MS, Rodney J. Landreneau, MD, and Arjun Pennathur, MD Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, and The University of Pittsburgh Cancer Institute Biostatistics Facility, Pittsburgh, Pennsylvania Background. With an increase in the performance of laparoscopic antireflux procedures, more patients with a failed primary antireflux operation are being referred to thoracic surgeons for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery. Methods. We conducted a retrospective review of patients who underwent redo surgery for failed fundoplication. The primary endpoint was failure of the redo operation; other endpoints included gastroesophageal reflux disease-health-related quality of life (HRQOL) after redo fundoplication. Results. A total of 275 patients (median age, 52 years; range, 17 to 88 years; men 82, women 193) underwent redo antireflux surgery. The most common pattern of failure of the initial operation was transmediastinal migration-recurrent hernia in 177 patients (64%). Redo surgery included Nissen fundoplication in 200 (73%), Collis gastroplasty in 119 (43%), and partial fundoplication in 41 (15%). There was no perioperative mortality. At a median follow-up of 39.6 months, 31 patients (11.2%) had a failure of the redo surgery, requiring reoperation. The two-year estimated probability of freedom from failure was 93% (95% confidence interval 89% to 96%). The HRQOL scores, available for 186 patients, were excellent to satisfactory in 85.5%, and poor in 14.5%. Conclusions. Redo antireflux surgery can be performed safely in experienced centers with outcomes that are similar to published open results. Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of the procedure. Thoracic surgeons with significant laparoscopic and open esophageal surgical experience can perform minimally invasive, complex redo esophageal antireflux procedures safely with good results. (Ann Thorac Surg 2011;92: ) 2011 by The Society of Thoracic Surgeons An increasing number of minimally invasive antireflux procedures are being performed and patients are increasingly being referred to thoracic surgeons for complex redo operations for failed repairs [1, 2]. The failure rates for primary fundoplication range from 2% to 30% [3 8]. Although many patients with mild recurrent symptoms can be managed nonoperatively, 3% to 6% of primary antireflux procedures will require a reoperative intervention [9]. In a recent systematic review, approximately one-third of redo antireflux surgical procedures were performed laparoscopically [10]. The success rates for either open or laparoscopic reoperative surgery, however, are not equal to those of primary antireflux operations. Little and colleagues [3], in an important study, reported that only 84% of patients undergoing open reoperative antireflux Accepted for publication Feb 24, Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25 27, Address correspondence to Dr Luketich, Department of Cardiothoracic Surgery, University of Pittsburgh, 200 Lothrop St, Ste C-800, Pittsburgh, PA 15213; luketichjd@upmc.edu. surgery achieved a satisfactory result and the percentage of patients with satisfactory results declined to 42% in patients who had undergone three or more operations. Redo antireflux surgery is a complex operation, and a thorough evaluation is essential before treatment. One of our goals in patients with benign esophageal disease is esophageal preservation. There are several options for reconstructive antireflux surgery including redo fundoplication and Roux-en-Y near esophagojejunostomy, which is applicable particularly in obese patients. After multiple failed redo operations, esophagectomy may be the only viable option. The main objective of this study was to evaluate our experience with reoperative surgery, without resection, for failed primary fundoplication. Our primary aim was to evaluate the outcomes after reoperative antireflux surgery. Material and Methods We retrospectively reviewed our experience with patients who underwent reoperative surgery (excluding esophageal resection) at the University of Pittsburgh 2011 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 1084 AWAIS ET AL Ann Thorac Surg REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92: Medical Center from 1996 to 2008 after failed fundoplication. This study includes a follow-up of our original series [11] and was approved by our Institutional Review Board. As this was a retrospective study, individual patient consent was waived. Preoperative Evaluation and Investigations Patients who were candidates for reoperative antireflux surgery underwent a comprehensive evaluation, with a complete history and physical examination; investigations performed included barium esophagram, esophagogastroduodenoscopy, esophageal manometry, ph testing, and gastric emptying studies. In addition, the details of the previous operative procedure were reviewed prior to the reoperation. Data on preoperative variables, including gender, age, symptoms, type of surgery, and the pattern of failure, were collected. Dysphagia scores were assessed preoperatively and postoperatively (Table 1). Surgical Technique Our technique for a minimally invasive approach for redo operations has been detailed previously [11]. In brief, an arterial line is used to assess potentially labile hemodynamics due to a potential pneumothorax that can occur during the mediastinal dissection. An on-table endoscopy is performed to assess anatomic abnormalities and also to rule out esophageal mucosal lesions, such as high grade dysplasia or cancer, which may change our operative approach. This is followed by safe port placement, with the initial port placed by an open technique. Lysis of adhesions is performed systematically and meticulous dissection is commenced towards the hiatus. The short gastric vessels are divided, if not done during the prior operation. It is important to preserve the peritoneum covering the crura and preserve the integrity of the crura. Complete right and left crural mobilization are essential to hiatal mobilization and eventual primary closure. The utilization of a mesh can be limited with complete crural mobilization and preservation of the integrity of the crura. Hiatal dissection is started by staying on the crura, as this will limit intraoperative perforations and vagal injuries. Finally, the wrap is completely taken down and the normal anatomy is defined prior to reconstruction. Removal of the gastroesophageal fat pad, if not done in the prior operation, allows for accurate recognition of the gastroesophageal junction; this is important for proper placement of the wrap and to assess the presence of a short esophagus. The esophagus is completely mobilized, including mediastinal mobilization. If 3 cm of tension-free intraabdominal esophagus is not achieved, an esophageal lengthening procedure is Table 1. Dysphagia Score Scale 1 no dysphagia 2 unable to swallow hard solids 3 unable to swallow soft solids 4 unable to swallow liquids 5 unable to swallow saliva Fig 1. Construction of the neoesophagus with an endo GIA (gastrointestinal anastomosing) stapler. (Reprinted from Pierre AF, et al, Ann Thorac Surg 2002;74: [12], with permission from Elsevier.) added. A Collis gastroplasty is performed by making a transgastric window with an end-to-end anastomosis stapler [12] (Fig 1), and more recently as a wedge gastroplasty with a linear stapler [9]. A short, floppy Nissen fundoplication is constructed over a bougie while the crura are approximated primarily. A distal esophageal myotomy may be considered for patients whose motility studies suggest pseudoachalasia [13]. Finally, our technique of Roux-en-Y near esophagojejunostomy, as described previously, can be considered in patients who are obese [14]. Patients were monitored during visits to the thoracic surgery clinic. The current follow-up schedule in the clinic is two weeks after discharge, every three months for two years, every six months for two additional years, and then annually. Quality of Life We assessed quality of life by administering the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL) questionnaire [15] and the Short Form 36-Item Health Survey (SF-36). The SF-36 is an instrument that measures the general health-related quality of life and is a well-established instrument used in a variety of conditions. The SF-36 estimates both the physical and mental components of the quality of life [16], which are aggregated to two summary measures: physical component score (PCS) and mental component score (MCS). The SF-36 transformed summary PCS and MCS scores were derived using the Quality Metric software program (Quality Metric, Lincoln, RI). The GERD- HRQOL questionnaire is a disease-specific instrument consisting of nine questions (recently expanded to 10) related to heartburn, regurgitation, dysphagia, diet, and bloating, with responses from 0 to 5.The best possible score (no symptoms) is 0 and the worst possible score

3 Ann Thorac Surg AWAIS ET AL 2011;92: REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 1085 (most severe symptoms) is 50 [15]. We classified HRQOL scores as excellent (0 9), satisfactory (10 15), or poor (16 50) [11]. Statistical Design and Analysis The primary outcome variable was failure of the redo procedure requiring reoperation and secondary endpoints included the quality of life measures after redo surgery. Kaplan-Meier plots were constructed using Greenwood confidence limits for estimation of failurefree survival. The time-to-failure analysis was performed from the time of the first reoperation performed by our group. In addition, analysis of individual covariates predictive of failure was performed with the Wald test. Comparison of dysphagia scores was done by the signed rank test. Results Patient Characteristics There were 275 patients who underwent surgery for failed primary fundoplication. Their median age was 52 years (range, 17 to 88 years). The majority of patients had one prior antireflux surgery; 31 patients (11.3%) had more than one prior antireflux procedure. Patient characteristics are summarized in Table 2. The most common presenting symptoms were heartburn in 63.6% (175 of 275), and dysphagia in 49.5% (136 of 275). Other presenting symptoms included regurgitation in 32% (88 of 275), and atypical symptoms in 29.5% (81 of 275) of patients. A preoperative upper endoscopy (273 of 275; 99.3%) and contrast swallow evaluation (266 of 275; 96.7%) were performed in nearly all patients. Upper endoscopy was abnormal in 82% of patients. Manometry with or without ph testing was obtained in 75% of patients (206 of 275). Manometry was abnormal in 55% of patients (151 of 275). These tests were not performed when a clear anatomic defect was noted on barium contrast swallow or upper endoscopic examination. Gastric emptying studies were obtained more selectively (146 of 275; 53.1%). The median Table 2. Patient Characteristics Characteristic No. (%) Total patients: 275 Gender male 82; female 193 Median age 52 years (range, years) Single redo surgery 244 Multiple redo surgeries 31 Type of operation: Nissen fundoplication 200 (72.7%) Partial fundoplication 41 (14.9%) Collis gastroplasty 119 (43.3%) Roux-en-Y 34 (12.4%) Myotomy 5 (1.8%) Additional procedures: Pyloroplasty 9 (3.3%) Table 3. Patterns of Failure Reason for Failure No. (%) Mediastinal migration of wrap, 177 (64.4%) hiatal hernia Short esophagus 119 (43.3%) Misplaced wrap 45 (16.4%) Loose wrap 12 (4.4%) Tight wrap 26 (9.5%) Disrupted wrap 11 (4%) Not determined 22 (8%) time from the prior operation to the redo operation was 36 months. Patterns of Failure of the Prior Operation and Reoperative Surgery Transmediastinal migration of the wrap or a recurrent hiatal hernia (177 of 275; 64.4%) was the most common cause of failure of the prior antireflux operation. Esophageal shortening was noted in 119 patients (119 of 275; 43.3%) and a defect in the crural repair was identified in 12 patients (4.4%) (Table 3). The most common procedure during reoperation was a Nissen fundoplication with or without a Collis gastroplasty (Table 2). The redo procedure was accomplished in a minimally invasive fashion in 93% of patients (256 of 275; 93%). There were eight conversions to open surgery due to extensive adhesions or a recognized intraoperative perforation. Nine operations were started in an open fashion. Mesh was utilized in 22 patients (8%; 22 of 275) as a component of the repair. Major complications included postoperative leaks, which occurred in 9 patients (3.3%), bleeding in 2 ( 1%), atrial fibrillation in 6 (2.2%), pulmonary embolism in 2 ( 1%), and Clostridium difficile colitis in 2 patients ( 1%). Reexploration was required in 4 patients (1.4%) for complications related to leak or bleeding. There was no perioperative mortality. The length of stay ranged from 1 to 75 days with a median length of stay of 3 days. Failure of the Redo Operation During follow-up of up to 14.5 years (median follow-up 3.3 years [39.6 months]; interquartile range 1 to 6 years), 31 patients (11.3%) had failure of the redo operation requiring surgical intervention. A redo fundoplication was performed in 7 patients, redo fundoplication with Collis gastroplasty in 7 patients, a Roux-en-Y esophagojejunostomy in 12 patients, and pyloroplasty in 1 patient. An esophagectomy was required in 4 patients. The estimated probability of freedom from failure was 95% at one year (95% confidence interval [CI] 92% to 97%), 93% at two years (95% CI 89% to 96%), and 84% at five years (95% CI 77% to 88%) (Fig 2). Covariates were analyzed to evaluate association with failure (Table 4). Age and partial fundoplication were significantly associated with failure of the redo operation. There was a trend for multiple redo operations to be associated with failure.

4 1086 AWAIS ET AL Ann Thorac Surg REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92: Fig 2. Kaplan-Meier plot of the probability of failure-free survival. Bars are 95% confidence intervals for probability of failure. Improvement in Symptoms and Quality of Life Paired dysphagia scores were obtained for 135 patients. There was a significant decrease in dysphagia after the redo procedure. The dysphagia score decreased significantly from 2.7 to 1.4 after redo surgery (signed rank test p ) (Fig 3). Routine clinical follow-up was complete in all patients. Detailed follow-up with quality of life questionnaires was available in 186 patients (68%; 186 of 275). During followup, the median GERD-HRQOL postoperatively was 5 (range, 0 to 35). The GERD-HRQOL was excellent in 52.2% (97 of 186) of patients, satisfactory in 33.3% (62 of 186), and poor in 14.5% (27 of 186) of patients. The general quality of life was also evaluated with the SF-36 instrument in a subset of patients. The median PCS was and the mean PCS SEM (standard error of the mean) was (normal 50). The median MCS was and the mean MCS SEM was (normal 50). Comment Reoperative antireflux surgery presents a challenging problem for surgeons, and referrals for failed fundoplication have increased due to the dramatic increase in antireflux surgery in the 1990s [2]. The surgical options that allow esophageal preservation for recurrent reflux disease after failed fundoplication include performance of another fundoplication and the construction of a Roux-en-Y near esophagojejunostomy. In this series, we have presented our results of reoperative surgery in 275 patients with a failed antireflux operation and found that laparoscopic redo antireflux surgery can be performed safely with outcomes that are similar to published open results. Recurrence requiring reoperation occurred in 11.3% of patients at a median follow-up of 3.3 years. The estimated probability of freedom from failure was 93% at two years, and most patients experienced resolution of dysphagia and a good quality of life after redo antireflux surgery. The classical approach to reoperative antireflux surgery is transthoracic [3, 17, 18]. The potential advantages of a transthoracic approach are its applicability in patients with multiple prior abdominal operations, hostile abdomen, and when a Belsey fundoplication is chosen by the surgeon. A transabdominal approach facilitates other intraabdominal procedures (for example, pyloroplasty or Roux-en Y esophagojejunostomy). In a recent systematic review of patients who underwent reoperative surgery after a failed antireflux operation, a transabdominal approach was used in approximately 66% of patients and a transthoracic approach in approximately 25% [10]. Reports of minimally invasive laparoscopic reoperative surgery for failed antireflux procedures are becoming more common [7 11, 19] and our primary approach for redo antireflux procedures is a laparoscopic approach. Clinical Presentation and Evaluation The primary symptoms prompting reoperation reported in the literature are recurrent reflux and dysphagia, similar to the primary symptoms seen in this series [10]. Dysphagia after primary antireflux surgery can be multifactorial and includes both anatomic problems with the repair (tight wrap, long wrap, twisted fundoplication, recurrent hernia) and esophageal dysfunction [13]. In Table 4. Analysis of Covariates Associated With Failure Factor Subgroup Hazard Ratio 95% CI p Value Gender Male Ref Female Age Type of procedure Redo number Time to redo surgery CI confidence interval. Complete fundoplication (Nissen) Ref Partial fundoplication(belsey/dor/toupet) Ref 2 or

5 Ann Thorac Surg AWAIS ET AL 2011;92: REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 1087 Fig 3. Frequency histograms of dysphagia scores (A) before (PRE) and (B) after (POST) reoperative antireflux surgery. Lower scores indicate improved dysphagia. Postoperative scores were significantly lower (improved) (signed rank p ). addition, persistent reflux can cause damage that leads to functional and anatomic impairment of the esophagus. This, coupled with prior procedures with injury to the gastroesophageal junction and possible compromise of the integrity of the vagi, adds to the complexities of a redo antireflux operation. Reoperative antireflux surgery is a complex operation and patients should be comprehensively evaluated prior to consideration for surgery. In particular, a barium esophagogram and esophagogastroscopy are very useful and provide a good delineation of the anatomic abnormalities, such as a misplaced wrap or tight wrap, and can rule out esophageal neoplasia, which would require a different approach. These investigations were utilized in nearly all the patients in our series. Esophageal function tests (manometry, ph testing) also provide useful information; for example, a patient with recurrent pathologic reflux who has abnormal peristalsis and contractility with dysphagia may require a partial fundoplication. However, these tests are not absolutely necessary when there is a clear anatomic defect noted on barium contrast swallow or upper endoscopic examination, explaining the patients symptoms. In patients with a suspected vagal injury, a gastric emptying study should be obtained. Causes of Failure of the Primary Operation The most common pattern of failure observed in this series was a transmediastinal migration of wrap, essentially a recurrent hiatal hernia. These findings are consistent with other large reoperative laparoscopic experiences [8, 10]. In a systematic review of more than 4,000 patients, transdiaphragmatic migration of the fundoplication and disruption of the wrap were the most common reasons for failure [10]. Factors potentially playing a role in recurrent hiatal hernia are an unrecognized short esophagus, creating longitudinal tension on the fundoplication, and the mode of initial diaphragmatic closure. In our series, a short esophagus was present in approximately 40% of patients. It is critical to recognize a short esophagus. If we are unable to achieve 2.5 to 3 cm of tension-free intraabdominal esophagus after complete mobilization in the mediastinum, we add a Collis gastroplasty to the repair. Some authors have suggested the routine addition of a Collis gastroplasty after two failures [7]. Others have not routinely added a Collis gastroplasty in the management of large hiatal hernias [20]. Maziak and colleagues [21] reported that they performed a Collis gastroplasty for short esophagus in 91 of 94 patients with giant paraesophageal hernia with a very low rate of recurrent hernia. Similarly, Deschamps and colleagues [18] reported 62.7% utilization of Collis gastroplasty in their series of reoperative antireflux surgery. In this series of reoperative surgeries for failed fundoplication, we used Collis lengthening with extensive esophageal mobilization in 43% of patients. Secure crural closure is another important technical factor in reducing the risk of transdiaphragmatic herniation with a recurrent hernia. It is important to preserve the peritoneal lining covering the crura and preserve the integrity of the crura. In our series we were able to close the crura primarily in most patients and mesh was used sparingly. Another approach that has also been described is the routine use of pledgeted sutures to repair the crura in combination with a Collis gastroplasty [22]. Failure of the Redo Operation During a median follow-up of 39.6 months, 11% of the patients in this study had failure of the redo procedure requiring a reoperation. This is similar to other studies; Deschamps and colleagues [18] reported that 10.8% of patients required reoperation at a median follow-up of 31 months. Stirling and Orringer [17] reported that 12 of 73 patients required another reoperation at a mean follow-up of 28 months. The causes for failure of the redo antireflux operation have been evaluated in few studies [3, 18]. Gender and time from prior operation were not significantly associated with failure of the redo operation in our study and partial fundoplication was significantly associated with failure of the redo operation. However, a partial fundoplication was primarily performed in patients with esophageal dysmotility; therefore, the baseline esophageal function may, at least in part, be a factor in the ultimate outcome. Further work is required to fully address confounding variables, such as esophageal dysfunction, and the association of the partial wrap with failure of the redo operation. We also observed a trend of failure of the reoperation with an increasing number of prior redo antireflux operations, a finding similar to that of Little and colleagues [3]. In contrast, Deschamps and colleagues [18] did not find that the number of prior redo operations was a significant factor in failure. These authors reported that primary obstructive symptoms of dysphagia requiring early dilations may be a marker of long-term failure of a redo operation. The procedure of choice after one or more failed fundoplications depends on many factors and the decision should be individualized. We attempt to tailor our

6 1088 AWAIS ET AL Ann Thorac Surg REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92: approach to the specific patient, based on preoperative testing, clinical symptoms, and intraoperative findings. For example, a patient who has an obvious recurrence due to the failure to recognize a short esophagus may benefit from another attempted repair with the addition of a Collis gastroplasty. Finally, comorbid conditions should be taken into consideration before redo antireflux surgery. Obesity is associated with gastroesophageal reflux [23]. Obese patients who present with recalcitrant symptoms after antireflux surgery can be considered for a Roux-en-Y near esophagojejunostomy [14]. In patients with severe loss of esophageal function, esophagectomy may offer a better and more definitive option when the gastroesophageal antireflux mechanism cannot be restored [9, 14, 17, 24, 25]. Some patients have severe, complicated reflux disease (for example, a long esophageal stricture resistant to dilation) and these patients are perhaps best served with an esophagectomy. Quality of Life One of the difficulties in follow-up of patients is the systematic assessment and standardized reporting of postoperative symptomatic improvement. We utilized a standardized disease-specific instrument, the GERD- HRQOL questionnaire, to assess symptomatic improvement. More than 85% of patients had excellent or satisfactory results after reoperative surgery for a failed prior antireflux operation. These results are comparable with other series of reoperative surgery and with a recent systematic review demonstrating successful symptom resolution in 81% of patients [10]. Strengths and Limitations This series is one of the largest experiences of redo surgery with esophageal preservation after failed fundoplication. A unique feature of this experience is that the majority of procedures were performed in a minimally invasive fashion by thoracic surgeons. Limitations include those common to retrospective studies, such as selection bias of treatment and limitations in data collection in a retrospective study. In addition, longer follow up is required for greater maturity of time-to-event data to allow for a more complete evaluation of failure of the redo operation. In addition, further work is required to delineate the risk factors for failure of the redo operation. Summary and Conclusions Redo surgery after failed fundoplication is a complex operation, and a comprehensive evaluation should be completed prior to performing the procedure. Redo antireflux surgery can be performed safely in experienced centers and as expected the outcomes after redo antireflux surgery are not as good as first time procedures. The operative approach depends on the underlying cause of failure. The reoperative procedure entails complete takedown of the previous repair, defining the gastroesophageal junction after dissection of the gastroesophageal fat pad, reestablishment of normal anatomy, maintaining vagal nerve and crural integrity, recognition of a short esophagus and the addition of an esophageal lengthening procedure if needed, and the proper construction of the fundoplication [9, 25]. Thoracic surgeons with significant laparoscopic and open esophageal surgical experience can perform minimally invasive complex redo esophageal antireflux procedures safely, with excellent-tosatisfactory results possible in more than 80% of patients using minimally invasive techniques at an experienced center. References 1. Dallemagne B, Taziaux P, Weerts J, Jehaes C, Markiewicz S. Laparoscopic surgery for gastroesophageal reflux. [In French] Ann Chir 1995;49: Ohnmacht GA, Deschamps C, Cassivi SD, et al. Failed antireflux surgery: results after reoperation. Ann Thorac Surg 2006;81: Little AG, Ferguson MK, Skinner DB. Reoperation for failed antireflux operations. J Thorac Cardiovasc Surg 1986;91: DeMeester TR, Bonavina L, Albertucci EM. Nissen fundoplication for gastroesophageal reflux disease: evaluation of primary repair in 100 consecutive patients. Ann Surg 1986; 204: Hiebert CA, O Mara, CS. The Belsey operation for hiatal hernia: a twenty-year experience. Am J Surg 1997;137: Peters JH, DeMeester TR. Indications, benefits and outcomes of laparoscopic Nissen Fundoplication. Dig Dis 1996;14: Hunter JG, Trus TL, Branum GD, Waring JP, Wood WC. A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 1996;223: Smith DC, McClusky DA, Rajad MA, Lederman AB, Hunter JG. When fundoplication fails: redo? Ann Surg 2005;241: Morse C, Pennathur A, Luketich JD. Laparoscopic techniques in reoperation for failed antireflux repairs. In: Patterson GA, Pearson FG, Cooper JD, et al, eds. Pearson s textbook of thoracic and esophageal surgery. Philadelphia, PA: Churchill Livingstone; 2008: Furnée E, Draaisma WA, Broeders IAMG, Gooszen HG. Surgical reintervention after failed antireflux surgery: a systematic review of the literature. J Gastrointest Surg 2009; 13: Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Ikramuddin S, Schauer PR. Outcomes after minimally invasive reoperation for gastroesophageal reflux disease. Ann Thorac Surg 2002;74: Pierre AF, Luketich JD, Fernando HC, et al. Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients. Ann Thorac Surg 2002;74: Stylopoulos N, Bunker CJ, Rattner DW. Development of achalasia secondary to laparoscopic Nissen fundoplication. J Gastrointest Surg 2002;6: Awais O, Luketich J, Tam J, et al. Roux-en-Y gastric bypass of intractable gastroesophageal reflux after antireflux surgery. Ann Thorac Surg 2008;85: Velanovich V, Vallance SR, Gusz JR, Tapia FV, Harkabus MA. Quality of life scale for gastroesophageal reflux disease. J Am Coll Surg 1996;183: Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30: Stirling MC, Orringer MB. Surgical treatment after the failed antireflux operation. J Thorac Cardiovasc Surg 1986;92:

7 Ann Thorac Surg AWAIS ET AL 2011;92: REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION Deschamps C, Trastek VF, Allen MS, Pairolero PC, Johnson JO, Larson DR. Long-term results after reoperation for failed antireflux procedures. J Thorac Cardiovasc Surg 1997;113: Papasavas PK, Yeaney WW, Landreneau RJ, et al. Reoperative laparoscopic fundoplication for the treatment of failed fundoplication. J Thorac Cardiovasc Surg 2004;128: Altorki NK, Yankelevitz D, Skinner DB. Massive hiatal hernias: the anatomic basis of repair, J Thorac Cardiovasc Surg 1998;115; Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management, J Thorac Cardiovasc Surg 1998;115; DISCUSSION DR DANIEL J. BOFFA (New Haven, CT): That was a very nice talk, Omar. How many of the patients were done at Pittsburgh primarily, and are there any tricks that you do during your first operation that make redos easier? And how many of the original antireflux procedures were done open as the first approach? DR AWAIS: Thank you Dan for your comments. In our ongoing analysis, approximately one-third of patients underwent their initial operation elsewhere. In regards to initial operative approach, about 10% of patients had a prior open operation; majority of the patients had laparoscopy as their initial approach. Although all redo antireflux operations are challenging, there are some tricks we use to potentially make them easier. Our goal is always to do it right the first time so that we do not have to reoperate. It all starts with the initial and accurate assessment of the patient s symptoms and their correlation with objective tests. We believe long-term success of the original operation depends on proper diagnosis and indication for the procedure, and during the operation, dissection of the hernia sac with reduction of the hernia, adequate esophageal and crural mobilization with preservation of crural lining, recognition of short esophagus, use of a Collis lengthening when indicated, secure crural closure, and proper construction of a fundoplication. In our initial operation we are extremely careful in identifying and preserving both the anterior vagus and the posterior vagus nerves. We reflect both nerves off the esophagus in order to place our fundoplication within both nerves. The success of the initial operation and the reoperation depends on all these factors and consistently following these steps during our original surgery allows us to avoid a reoperation. DR THOMAS FABIAN (Albany, NY): Omar, congratulations on a nice presentation. What percentage, and I may have missed it, were second-time redos and third-time redos? And if you have that information, did you compare patient satisfaction between those groups, and how did it modify your technical approach to repairing them? DR AWAIS: Thank you, Tom. In our series, 31 patients underwent two prior operations and very few patients had three or more. Our approach to all redos regardless of number of prior operations is the same, that is comprehensive evaluation, and when we reoperate, would be to reestablish normal anatomy, preserve both vagi, recognize a short esophagus, and reconstruct a new fundoplication. 22. Whitson BA, Hoang CD, Boettcher AK, Dahlberg PS, Andrade RS, Maddaus MA. Wedge gastroplasty and reinforced crural repair: important components of laparoscopic giant or recurrent hiatal hernia repair. J Thorac Cardiovasc Surg 2006;132: Fisher BL, Pennathur A, Mutnick JL, Little AG. Obesity correlates with gastroesophageal reflux. Dig Dis Sci 1999;44: Gadenstätter M, Hagen JA, DeMeester TR, et al. Esophagectomy for unsuccessful antireflux operations. J Thorac Cardiovasc Surg 1998;115: Pennathur A, Awais O, Luketich JD. Minimally invasive redo antireflux surgery: Lessons learnt. Ann Thorac Surg 2010;89: S We did not perform any subset analysis in comparing patient satisfaction between those groups. DR MARK B. ORRINGER (Ann Arbor, MI): I compliment you for a well presented paper. Your statement that reoperative antireflux surgery is advanced esophageal surgery cannot be overemphasized. And results such as those you have reported require experience and a large volume of these patients. Despite the unquestioned experience of your group, I am concerned about your results. As a Belsey disciple, I recall a number of us having to twist Belsey s arm to let us report the results of the Belsey Mark IV operation, which he did not want to do until he had ten years of follow-up. The abstract of your paper indicates that you have 23 months of mean follow-up in these patients. You already report a nearly 10% incidence of need to reoperate, and that is extremely worrisome and portends an unacceptable failure rate. Can you comment upon your relatively high reoperative rate? Further, you use mesh in 24% of your patients. In all the years that I have performed antireflux-hiatal hernia operations, I have never used mesh at the hiatus. Placing a semi-rigid material against an organ that is constantly moving up and down with diaphragmatic excursions leads to esophagogastric erosion, which we are now called upon regularly to treat. Such a complication is a disaster for the patient and generally leads to an esophagectomy. I personally believe that there is nothing like being able to do these operations open, palpate and grasp the tendinous hiatus, and place reliable hiatal sutures that obviate the need for mesh. Have you experienced such problems with mesh erosion in your patients? Finally, I question the value of manometric data in these redo patients. With a giant paraesophageal hernia and an accordioned, shortened esophagus, the barium swallow and manometry may show dysmotility. But this does not justify a myotomy or partial fundoplication. An esophageal lengthening Collis gastroplasty and Nissen fundoplication straighten the esophagus, and the preoperative dysmotility seen on manometry has little clinical significances. Similarly, after several antireflux operations and a partially obstructed esophagogastric junction, manometry may show dysmotility, but the type of fundoplication performed should not be influenced by this. Do you really alter your redo operation based upon preoperative manometric findings? I d also like to hear your thoughts on the limit of the number of hiatal hernia-antireflux operations a patient can have before you say that another fundoplication is destined to failure and a different approach is needed. How many redo laparoscopic

8 1090 AWAIS ET AL Ann Thorac Surg REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92: repairs are you willing to do? What dictates your decision to do something more than just a redo fundoplication? I very much enjoyed your paper. DR AWAIS: Thank you, Dr Orringer, for your comments. We acknowledge your significant contributions in this field. We almost never use mesh during our initial operation and in this series we report mesh utilization in less than 10% of our patients in a reoperative setting. I concur that mesh placement at the hiatus should be avoided if at all possible and we only reserve its utilization in situations in which the crural integrity is destroyed. I agree with you entirely that these are very complicated patients who should be managed at high volume centers for best outcomes. We agree that these outcomes can be better evaluated with longer follow-up. However, our mean follow-up of 23 months compares well to some of the other, few, large reported series, and some series suggest that most recurrence occur within the first two years. With ongoing follow-up, we have now extended our median duration of follow-up beyond 36 months. We continue to monitor and follow-up our patients. And the answer to how many operations you need to do as an endpoint for a potential esophagectomy, I think that depends on many factors. One, it depends on the patient s preoperative symptoms, such as dysphagia, and some of the objective tests we use in our evaluation as well as number of redos. Our goal, always the first time out, is to try to avoid a reoperative fundoplication but, as you can see, the results are not as good, based on many series, as you perform second, third, or fourth redo. We see a wide spectrum of patients starting with a young patient with obvious anatomic problem, good motility, and normal weight. This patient would obviously be served best by a redo fundoplication. In contrast, on the other side of the spectrum, we may see a patient with multiple redos, severe dysmotility, dysphagia, and poor emptying. In such a patient esophagectomy may be the best option. In reality, most patients present somewhere in between these two extremes and for these we do not have all the answers. They must be studied extensively and approached individually. We must tailor the operation based on their symptoms, based on their preoperative evaluation, and also perhaps BMI [body mass index]. Finally, I would stress during the initial visit all three options, esophagectomy, fundoplication, and Roux-en-Y are discussed in detail with the patient, because sometimes you never know what you will find in the OR. Member and Individual Subscriber Access to the Online Annals The address of the electronic edition of The Annals is If you are an STS or STSA member or a non-member personal subscriber to the print issue of The Annals, you automatically have a subscription to the online Annals, which entitles you to access the full-text of all articles. To gain full-text access, you will need your CTSNet user name and password. Society members and non-members alike who do not know their CTSNet user name and password should follow the link Forgot your user name or password? that appears below the boxes where you are asked to enter this information when you try to gain full-text access. Your user name and password will be ed to the address you designate. In lieu of the above procedure, if you have forgotten your CTSNet username and/or password, you can always send an to CTSNet via the feedback button from the left navigation menu on the homepage of the online Annals or go directly to We hope that you will view the online Annals and take advantage of the many features available to our subscribers as part of the CTSNet Journals Online. These include inter-journal linking from within the reference sections of Annals articles to over 350 journals available through the HighWire Press collection (HighWire provides the platform for the delivery of the online Annals). There is also crossjournal advanced searching, etoc Alerts, Subject Alerts, Cite-Track, and much more. A listing of these features can be found at We encourage you to visit the online Annals at ats.ctsnetjournals.org and explore by The Society of Thoracic Surgeons Ann Thorac Surg 2011;92: /$36.00 Published by Elsevier Inc