failed fundoplication surgery
DESCRIPTION
Presentation from a postgraduate course for the 2011 meeting of the Society for Surgery on the Alimentary Tract Annual Meeting.TRANSCRIPT
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• No financial or other relationship with any product or treatment discussed in this talk
Conflict of Interest / Disclosure
Re-Operations for Failed Anti-Reflux and Failed PEH Procedures
C. Daniel Smith
SSAT MOC CourseThe Surgeon in the Management of
Gastric & Esophageal Diseases
May 7, 2011Chicago, Illinois
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ARS & PEH – Failure Happens
• Anti-reflux Surgery Failure
- 5-40%
- Redo vs. back on PPIs
• PEH Failure
- 25-40%
- ? anatomic vs. clinical failure
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Failed ARS & PEH – Management Challenging
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• What is failure?
• How to work-up?
• Decision about redo
• Intraoperative- Technically demanding
- What to do (e.g., take down wrap, mesh, full wrap)
Redo ARS and PEH – Success is Possible
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307 redo fundoplications in 285 patients
1,89210 fundo internal
18710 fundo external 54 fail (2.8%)
421st redo external
22st redo external
17 fail (7.1%)
4 fail (6.8%)
1 fails (17%)
1st redo fundoplication241
2nd redo fundoplication59
3rd redo fundoplication6
4th redo fundoplication4th redo fundoplication
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Failed ARS & PEH – Keys to Success
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• Know patterns of failure
• Diagnostic work-up
• Patient selection
• Intraoperative management
ARS & PEH – Patterns of Failure
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ARS & PEH – Patterns of Failure
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ARS & PEH – Patterns of Failure
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• 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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Prior Antireflux / PEH Surgery
Redo Antireflux +/- G-tube
EGDBaSw
Anatomically Normal
Obvious Anatomic Problem
Confirm GERD
pHEMSGES
No GERD
Symptom Correlatio
n
EMSGES
Entertain Other Diagnosis
Patterns of
Failure
Failed ARS & PEH – Work-up
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• 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
Redo ARS & PEH – Patient Selection
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Not everyone with failure should have a redo
65 yo male, 6 years of good response, now with recurrent HB and hiatal hernia with wrap undone
Presentation Redo?
Easy Yes
32 yo female, never completely better after wrap, “loose wrap”, pH slightly increased
No
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Two Predictors of Outcome
Patient Selection
Operative Technique
Redo ARS & PEH – Operative Management
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• 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
Redo ARS & PEH – Summary
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• 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