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Neil R. Floch, MD; Ronald A. Hinder, MD, PhD; Paul J. Klingler, MD; Susan A. Branton, MD; Matthias H. Seelig, MD; Tanja Bammer, MD; Charles J. Filipi, MD

Arch Surg. 1999;134:733-737.

Hypothesis  Laparoscopic techniques can be used to treat patients whose antireflux surgery has failed.

Design  Case series.

Setting  Two academic medical centers.

Patients  Forty-six consecutive patients, of whom 21 were male and 25 were female (mean age, 55.6 years; range, 15-80 years). Previous antireflux procedures were laparoscopic (21 patients), laparotomy (21 patients), thoracotomy (3 patients), and thoracoscopy (1 patient).

Main Outcome Measures  The cause of failure, operative and postoperative morbidity, and the level of follow-up satisfaction were determined for all patients.

Results  The causes of failure were hiatal herniation (31 patients [67%]), fundoplication breakdown (20 patients [43%]), fundoplication slippage (9 patients [20%]), tight fundoplication (5 patients [11%]), misdiagnosed achalasia (2 patients [4%]), and displaced Angelchik prosthesis (2 patients [4%]). Twenty-two patients (48%) had more than 1 cause. Laparoscopic reoperative procedures were Nissen fundoplication (n=22), Toupet fundoplication (n=13), paraesophageal hernia repair (n=4), Dor procedure (n=2), Angelchik prosthesis removal (n=2), Heller myotomy (n=2), and the takedown of a wrap (n=1). In addition, 18 patients required crural repair and 13 required paraesophageal hernia repair. The mean±SEM duration of surgery was 3.5±1.1 hours. Operative complications were fundus tear (n=8), significant bleeding (n=4), bougie perforation (n=1), small bowel enterotomy (n=1), and tension pneumothorax (n=1). The conversion rate (from laparoscopic to an open procedure) was 20% overall (9 patients) but 0% in the last 10 patients. Mortality was 0%. The mean±SEM hospital stay was 2.3±0.9 days for operations completed laparoscopically. Follow-up was possible in 35 patients (76%) at 17.2±11.8 months. The well-being score (1 best; 10, worst) was 8.6±2.1 before and 2.9±2.4 after surgery (P<.001). Thirty-one (89%) of 35 patients were satisfied with their decision to have reoperation.

Conclusions  Antireflux surgery failures are most commonly associated with hiatal herniation, followed by the breakdown of the fundoplication. The laparoscopic approach may be used successfully to treat patients with failed antireflux operations. Good results were achieved despite the technical difficulty of the procedures.

From the Departments of Surgery, Mayo Clinic Jacksonville, Jacksonville, Fla (Drs Floch, Hinder, Klingler, Branton, Seelig, and Bammer), and Creighton University School of Medicine, Omaha, Neb (Dr Filipi).

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