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J Thorac Cardiovasc Surg 2004;128:509-516
© 2004 The American Association for Thoracic Surgery
General thoracic surgery |
a Division of Minimally Invasive Surgery, The Western Pennsylvania Hospital, Pittsburgh, Pa, USA
b Division of Thoracic Surgery, Allegheny General Hospital, Pittsburgh, Pa, USA
Read at the Eighty-second Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-8, 2002.
Received for publication May 3, 2002; revisions received April 7, 2004; accepted for publication April 14, 2004.
* Address for reprints: Robert J. Keenan, MD, Division of Thoracic Surgery, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, USA
rkeenan{at}wpahs.org
OBJECTIVE: This study was undertaken to determine the safety and efficacy of reoperative laparoscopic fundoplication for patients with failed fundoplication.
METHODS: Thirty-nine of 612 consecutive patients who had undergone fundoplication underwent laparoscopic reoperative fundoplication for recurrent symptoms, persistent dysphagia, or gas bloat. An additional 15 patients were referred from outside facilities for reoperation. Preoperative evaluation included barium swallow (n = 54), esophagogastroduodenoscopy (n = 54), esophageal manometry (n = 34), and 24-hour ambulatory pH measurement (n = 32). Symptom severity before and after surgery was evaluated with a visual analog scoring scale. The mean follow-up was 22.5 months.
RESULTS: The primary symptoms that led to reoperation in the 54 patients were heartburn (n = 26), dysphagia (n = 23), and gas bloat (n = 5). Average time from initial operation to reoperation was 22.7 months. There were 3 conversions to open technique. An anatomic reason for the failure of the initial fundoplication was found in 69% of cases: slipped or misplaced fundoplication (n = 14), disrupted fundoplication (n = 8), transdiaphragmatic herniation (n = 7), achalasia (n = 1), and tight fundoplication (n = 7). Fourteen patients had 15 perioperative complications. Mean hospital stay was 2.3 days. Symptoms such as heartburn, dysphagia, and gas bloat improved significantly after reoperation; 40% to 50% of patients had scores 0 to 2, 21% to 45% had scores 3 to 7, and 9% to 29% had scores 8 to 10. Proton-pump inhibitor use after operation decreased from 88% to 36%. Fifty-two percent of patients completely discontinued any antireflux medications. Three patients had failure of the reoperation and required additional procedures.
CONCLUSION: Laparoscopic reoperation for failed fundoplication is feasible and can achieve resolution of symptoms for a significant percentage of patients.
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