43: Management of the Failed Reflux Operation

Introduction

Management of the failed reflux operation is emerging as an important challenge in modern surgical foregut practice. Over the last decade and a half, the number of patients referred for antireflux surgery has increased eightfold. Approximately 70,000 operations are performed annually in the United States.¹ The increased use of minimally invasive techniques to treat gastroesophageal reflux disease (GERD) has resulted from the lower perceived morbidity associated with laparoscopy in comparison with the open approach.

Most patients who undergo laparoscopic antireflux surgery experience good long-term outcome. Specialty centers report 90% to 95% “sustained benefit” after initial surgery, although not all centers see their own complications.^2,3 The results published by the broader surgical community are less favorable.^3,4 This finding is similar for laparoscopic and open surgery. However, the results are subjective and depend on the definition of failure and the experience of the surgeon.^5-9

The failure of antireflux surgery may occur early or late. The etiology of the failure is associated with and is sometimes revealed by the timing of symptoms. Early failures can be attributed to poor patient selection and technical error.⁹ For example, the misdiagnosis of an unrecognized primary esophageal motility disorder (PEMD) may lead to improper choice of surgical procedure, which dooms the procedure to fail.^10,11 Late failures may be secondary to the progression of underlying disease or attributed to the length of the procedure.¹²

After several decades of experience, multiple reports of transient increases in failed antireflux procedures have ascribed these failures to the initial learning-curve effect,^13-15 modifications of surgical technique during the initial transition to laparoscopic approach,¹⁶ and relaxation of patient selection criteria. With growing experience in the thoracic community, however, these sorts of failures are expected to diminish.

Despite good surgical results after initial operation, some patients present with recurrent symptoms or mechanical failure. Most of these patients can be managed medically with good results. However, 4% to 10% of patients become or remain symptomatic with a poor quality of life and seek additional surgical therapy.^2,10,17-21 Success rates for reoperations range between 50% and 89%.⁶ Second and third reoperations traditionally are associated with lower success rates, decreasing as much as 20% with each subsequent operation.²² The technical difficulty of reoperation has led some surgeons to advocate an open approach.²³ Evidence supporting the safety and efficacy of laparoscopic reoperation, however, is increasing.^1,2,6,24 In our experience, the laparoscopic approach to reoperation is feasible in over 95% of patients regardless of the approach used for the primary or previous surgeries (e.g., open or laparoscopic, thoracic, or abdominal).

Reevaluation and Diagnosis

Determining the cause is the difficult aspect of reevaluating patients with recurrent reflux. First, ...