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Eur J Cardiothorac Surg 2004;26:875-880
© 2004 Elsevier Science NL

Redo antireflux surgery—the importance of a tailored approach

^a Thoracic Unit, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
^b GI Physiology Unit, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK

Received 18 January 2004; received in revised form 1 June 2004; accepted 23 July 2004.

^* Corresponding author. Tel./fax: +44-115-969-1169. (E-mail: omarkhan{at}iname.com).

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objective: Although several studies have examined early outcome following redo antireflux surgery, there is little data on the long-term efficacy of these procedures. We reviewed our experience of these operations in order to assess the long-term results which can be achieved by choosing redo antireflux procedures based on the results obtained from pre-operative oesophageal function testing. Methods: The case notes of 26 patients who underwent a repeat antireflux procedure between 1981 and 2000 were reviewed. Clinical history, examination, endoscopy, pH studies, oesophageal manometry and video barium contrast studies were performed on all patients prior to re-operation. In all cases, a standardised pre-formulated algorithm, based on the results of the pre-operative oesophageal function tests, was used to determine the choice of surgical procedure. Post-operatively, patients were classified into three groups: Group A (those with no symptoms), Group B (symptoms controlled by medication) and Group C (symptoms refractory to medical treatment). Patients in Groups B and C underwent repeat oesophageal function studies. Results: In all cases, the indication for re-operation was gastro-oesophageal reflux symptoms refractory to medical treatment. Twenty-one patients (81%) underwent a left thoracotomy, of whom 11 patients (42%) underwent a gastroplasty. The mean follow-up period was 8.27 years (range 1.5–19.8 years), after which 14 patients (54%) were classified as Group A; 10 patients (38%) as Group B; and 2 patients (8%) as Group C. Within Groups B and C, manometry showed that re-operation had increased basal lower oesophageal sphincter pressure (4.6 vs 12.7mmHg, pre- vs post-operative P=0.03), and in all, but one case pH studies showed no evidence of recurrent acid reflux. Conclusions: Redo antireflux surgery can provide complete symptomatic relief in approximately 50% of patients and symptomatic improvement over 90% of patients. We advocate a tailored approach in the selection of re-operative procedures based on the results of pre-operative oesophageal function testing.

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Antireflux surgery is a well-established technique in the management of refractory gastro-oesophageal reflux disease. Although, antireflux surgery has shown to be highly effective in providing long-term symptomatic relief up to 90% of cases, the remaining patients develop recurrent or new symptoms following surgery [1]. Since the introduction of laparoscopic fundoplication [2] there has been a steady increase in the number of primary antireflux procedures performed [3]. As a consequence of this expansion, a larger number of patients are presented with recurrent symptoms, some of whom undergo further surgical procedures. Although a number of studies have examined early outcome following such repeat antireflux procedures [4–8], there is limited data on the long-term term efficacy of these operations. The purpose of our study was to review our experience of repeat antireflux procedures and to analyse our long-term results.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
The case notes of all patients who underwent elective re-operative antireflux surgery for recurrent gastro-oesophageal reflux disease and associated complications between January 1981 and December 2000 were reviewed. All patients had previously undergone a single open antireflux procedure either in our unit or in other centres. Exclusion criteria included patients who had previously undergone resectional surgery, those with scleroderma or achalasia and patients who had undergone more than one antireflux procedure in the past. Following these exclusions, the results of 26 patients were studied in detail.

2.1. Pre-operative assessment
Patients were assessed by means of clinical history, physical examination and routine biochemical and haematological investigations. In addition, all patients underwent detailed pre-operative oesophageal function testing including video barium contrast studies, 24h pH monitoring and oesophageal manometry. Video barium contrast studies were performed in order to visualise the foregut anatomy as well as to identify and classify any hiatus herniae using previously published criteria [6]. Oesophageal manometry was performed by a single observer and oesophageal peristalsis was classified into four categories: good, moderate, poor or very poor motility. Reflux was quantified by measuring the percentage of time over a 24-h period that the pH of the oesophagus at a point, 5cm above the manometrically defined gastro-oesophageal junction remained below four; with the normal range being defined as less than 4%. All patients also underwent oesophagogastroscopy in order to assess the position of the gastro-oesophageal junction and to exclude any undiagnosed malignancy. In addition, the presence of Barretts oesophagus and oesophagitis was noted and graded according to previously published criteria [9].

2.2. Indications for surgery
All patients underwent a trial of appropriate medical therapy with a variety of drugs including H2-receptor antagonists, alginic acid preparations, prokinetic agents and towards the end of the study period, proton pump inhibitors. Only those patients with clinically disabling symptoms of gastro-oesophageal reflux disease unresponsive to maximal medical treatment were selected for surgery.

2.3. Operative management
All operations were performed by the same team of four thoracic surgeons who utilised similar operative strategies and post-operative management. All operations were carried out through an open procedure (either a left thoracotomy or upper midline laparotomy). In each case, a pre-formulated algorithm, based on the results of patient's pre-operative investigations as well as the intra-operative findings, determined the actual choice of procedure. A summary of this algorithm is shown in Fig. 1. The rationale for adopting this approach is discussed later, but it should be noted that in cases where gastroplasty was deemed appropriate, our unit policy was to perform a total fundoplication gastroplasty, with the length of the wrap tailored according to previously published criteria [10,11].

View larger version (21K): [in this window] [in a new window]   Fig. 1. Simplified algorithm for the selection of an appropriate redo antireflux procedure.

2.4. Post-operative assessment
Our unit policy is of life-long follow-up and there was a 100% follow-up rate. All patients were interviewed and examined at outpatient clinic at the following time periods: 6 weeks after the operation; 3 monthly for the first year; 6 monthly for the second year; yearly until the 10th year and every 2 years thereafter. Patients were specifically asked for the presence of recurrent symptoms of reflux as well as new symptoms including dysphagia, odynophagia, nausea, difficulties in belching, abdominal pain, symptoms of gas bloat syndrome and post-thoracotomy incisional pain. All patients who reported gastrointestinal symptoms following surgery underwent re-investigation with repeated pH studies, oesophageal manometry, video barium swallows and oesophagogastroscopy. These patients were then commenced on a trial of appropriate medical or surgical therapy.

Patients who were completely asymptomatic following surgery were classified as Group A (excellent result); those who had recurrent symptoms or new symptoms, but who then responded completely to medical treatment were classified as Group B (satisfactory result); and those with recurrent or new symptoms refractory to medical treatment were classified as Group C (failures). The mean follow-up period was 8.27 years (range 1.5–19.8 years).

2.5. Statistical analysis
Statistical analysis was performed using commercially available software. Comparison between pre-operative and post-operative variables was performed using a chi test for categorical variables and the Student's t-test for continuous data. P values of less than 0.05 were considered statistically significant. Unless stated otherwise, data was expressed as a mean with SD in parenthesis.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
3.1. Pre-operative clinical characteristics
Of the 26 patients, 12 were male and 14 female with a mean age of 48.6 years (range 17–73 years). The initial antireflux procedures performed on our cohort of patients are shown in Table 1. The mean time between the primary procedure and the development of recurrent symptoms was 29.4 months (range 3 months–8 years).

3.2. Pre-operative investigations
3.2.1. Manometry
Thirteen patients (50%) had good oesophageal body motility, eight patients (31%) had moderate motility, four patients (15%) had poor motility and one patient (4%) was found to have very poor motility. The mean lower oesophageal sphincter (LOS) pressure of the cohort was 7.2±2.97mmHg, and three patients were found to have no appreciable LOS pressure. A total of four patients (15%) had good oesophageal motility and a normotensive LOS.

3.2.2. pH studies
Within the cohort, the mean percentage time taken for the pH to drop below four over a 24-h period was 7.52±7.44. The results of eight (31%) patients were within the normal range as defined in the Section 2.

3.2.3. Oesophagogastroscopy results
Of the 26 patients, 10 patients (38%) were found to have oesophagitis (six, grade I; three grade II and one, grade III), six patients (23%) showed evidence of Barretts metaplasia and three patients (12%) were noted to have biliary reflux. Seven patients (27%) had no abnormality on oesophagogastroscopy.

3.2.4. Video barium results
Of the 26 patients, nine (35%) were noted to have sliding hiatus hernia associated with a intra-thoracic gastro-oesophageal junction, nine patients (35%) showed evidence of reflux, four patients (15%) showed evidence of a slipped Nissens fundoplication and three patients (12%) had a delay in gastric emptying. Three patients (12%) had no abnormality on barium swallow.

None of the patients had any haematological or biochemical abnormalities and amongst the cohort, every patient had an abnormality on at least one of the tests.

3.3. Operative treatment
The re-operations performed in our cohort of patients are shown in Table 2. There were no deaths, intra-operative complications or post-operative deaths. In terms of morbidity, two patients developed chest infections as evidenced by a productive cough and the presence of infiltrates on chest radiographs. These patients were managed with antibiotic treatment and physiotherapy. There were no recorded cases of oesophageal leaks, deep vein thrombosis, pulmonary embolism, myocardial infarcts, gastric perforations, wound infections or episodes of atrial fibrillation. The mean in-hospital stay was 6.5 days (range 4–12 days).

Of the remaining 12 patients, the following symptoms were noted: heartburn (eight patients), intermittent dysphagia (one patient), epigastric pain distinct from heartburn (one patient), gas bloating (one patient) and intermittent nausea (one patient).

The mean time between the redo procedure and the development of recurrent symptoms was 28.3 months (range 11 months–7.9 years). There was no difference in the results of pre-operative oesophageal function studies between those patients who remained asymptomatic and those who developed symptoms post-procedure.

All 12 patients with recurrent symptoms underwent repeat oesophageal function testing and their results were compared with their pre-operative results as shown below:

Video barium. Although all 12 patients showed pre-operative abnormalities on barium swallow, following surgery, only one patient showed any evidence of abnormalities (namely reflux).

pH studies. Within the group of 12 patients, re-operation caused a statistically significant decrease in the mean percentage time that dropped the pH below four over a 24-h period (4.41 vs 1.85, pre- vs post-operative P=0.03). Following redo surgery, only one of the 12 patients had evidence of significant acid reflux, as compared with nine patients who showed evidence of significant acidreflux pre-operatively.

Oesophagogastroscopy. None of the 12 patients had any abnormality on oesophagogastroscopy.

Manometry. Of the 12 patients, re-operation caused a statistically significant increase in basal LOS pressure (4.6 vs 12.7mmHg, pre- vs post-operative P=0.03).

3.5. Long-term results
Following repeat investigations, the 12 patients underwent appropriate therapy—namely medical treatment in 11 cases (typically with H2-receptor antagonists, or in the later stages of the study, proton pump inhibitors) and oesophageal dilatation with a Maloney bougie in one case. Following this treatment, 10 patients reported complete long-term cessation of symptoms. The remaining two patients, both of who were found to have no abnormalities on post-operative oesophageal function testing, remained symptomatic with heartburn. One of these patients declined to be considered for further surgery, whilst the other developed late-onset dysphagia 8 years after her redo procedure. This patient underwent repeated oesophageal dilations, but gained no symptomatic relief and eventually underwent an oesophagectomy.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Re-operative antireflux surgery represents a challenging and complex clinical undertaking requiring careful patient selection as well as a high level of technical expertise. The procedures themselves are associated with a high rate of morbidity and have quoted success rates as low as 66% in some series [12]. In this context, our results compare favourably with previously quoted studies—over 90% of our patients reported long-term symptomatic improvement following surgery. This figure is comparable to the only other series examining long-term outcome following re-operative surgery, which reported a success rate of 87% [4]. In addition, our patients appeared to have a relatively smooth post-operative recovery—only 8% of our patients suffering a significant post-operative complication, as compared with a rate of 25% reported by Deschamps et al. [4].

Although most studies advocate oesophageal function testing as important diagnostic tools, there is some controversy in the literature as to the efficacy of these tests in assessing the suitability of patients for surgery. For example, in primary antireflux surgery, Booth et al. [13] have shown that symptomatic patients with normal distal oesophageal acid exposure times and normal endoscopic examination do derive benefit from surgical intervention. Similarly, Mughal et al. [14] have shown that pre-operative oesophageal studies have minimal value in deciding the suitability of patients for surgical intervention. In this study, the decision to perform surgery was based on clinical grounds alone; with the results of the oesophageal function tests being used simply to select the appropriate redo procedure. This strategy of relying on clinical factors alone to determine the appropriateness of surgical intervention does appear to be justified, as all of our patients were noted intra-operatively to have a breakdown of their previous repair.

It should be noted that all of our patients underwent open, as opposed to laparoscopic procedures. The high rates of morbidity associated with open procedures have led some authors to advocate minimally invasive approaches in redo antireflux surgery. Although the in-hospital stay of our patients was longer as compared with some laparoscopic series [5,15], it should be noted that our morbidity rate was substantially lower than that of a recently published large-scale study of laparoscopic redo procedures [5]. This finding, together with the absence of any data concerning the long-term outcome of laparoscopic redo antireflux surgery means that, at present, we are not yet convinced of the superiority of laparoscopic over open procedures in redo surgery.

Within our cohort, the most commonly performed procedure was a total fundoplication gastroplasty. We performed gastroplasty in all cases where pre-operative results obtained from oesophagogastroscopy or video barium studies suggested the presence of oesophageal shortening; as well as cases where oesophageal shortening was noted intra-operatively. We also performed this procedure in all cases where pre-operative oesophagogastroscopy showed the presence of significant oesophagitis. Our rationale for performing gastroplasty even in cases of mild oesophagitis stems from our experience in primary antireflux surgery, where we found that oesophagitis was a predictor of long-term failure in cases where oesophageal lengthening was not performed [16]. It should be noted that whole question of oesophageal lengthening is a controversial subject. Studies of primary antireflux surgery have reported widely differing requirements for gastroplasty, with figures ranging from 4 to 8% [17,18]. With regard to redo procedures, there does appear to be more consistency in the literature regarding the need for oesophageal lengthening, with reported gastroplasty rates between 50 and 65% [4,5]. Ironically, despite our relatively liberal criteria for performing gastroplasty, our rate was only 42%. Nonetheless, it should be noted that our high long-term success rate does suggest that we are not inappropriately avoiding performing oesophageal-lengthening procedures.

Of our remaining patients, the majority underwent a trans-thoracic as opposed to an abdominal approach. The exact choice of thoracic procedure was once again based on our previously published experience in primary antireflux surgery—in the presence of impaired oesophageal motility a Belsey Mark IV was our preferred approach, whilst a Nissen fundoplication was reserved for cases with good oesophageal motility [19]. In addition, we performed an oesophagectomy and jejunal loop interposition grafting on one patient with very poor oesophageal motility. This procedure has been evaluated by Gaddensatter et al. [20] who reported oesophagectomy to be superior to standard antireflux procedures in cases of profound oesophageal dysmotility.

In this series, only 19% of our patients underwent an abdominal approach. This low rate reflects our strategy of contemplating an abdominal approach only in cases where pre-operative evaluation excluded the possibility that a gastroplasty or Belsey Mark IV procedure would be required. In practice, this meant reserving an abdominal approach for cases where pre-operative investigations showed unambiguous evidence of a long intra-abdominal oesophageal segment, good oesophageal motility and no evidence of oesophagitis. Of the patients who underwent an abdominal procedure, the most common redo operation was a Nissen fundoplication. However, our cohort also contained one patient with acid and biliary reflux who underwent an antrectomy and biliary diversion. Although this procedure is rarely performed for recurrent gastro-oesophageal reflux disease, it has been shown by some authors to be useful in complex cases [21]. Indeed the diversity of procedures performed on our cohort reflects our policy of performing an individually tailored approach based principally on the results of pre-operative investigations.

Although 42% of patients reported recurrent or new symptoms following their redo procedure, the majority of these patients showed improvements in their post-operative oesophageal function tests as well as complete cessation of symptoms following medical therapy. This finding raises the issue of the correlation between post-operative symptomatic improvement and changes in the results of oesophageal function tests. Donkervoort et al. [22] have recently shown that following primary antireflux surgery, post-operative abnormalities on barium swallow were not associated with symptomatic recurrence. Although at first glance, our study appears to suggest that improvements in oesophageal function tests post-procedure are in fact associated with symptomatic improvements, it should be noted that the two patients with refractory symptoms of reflux both showed no abnormalities on post-operative oesophageal function testing. The aetiology underlying these refractory symptoms is unclear. Previous studies have shown that psychological factors may be responsible for post-operative symptoms in patients who undergo technically successful antireflux surgery [23,24]. While this may in part explain the symptomatology of these two patients, the fact that one of the patients developed late-onset dysphagia does suggest that there was also a patho-physiological component to this phenomenon.

In summary, we have shown that redo antireflux surgery is a successful clinical intervention which can provide at least some long-term symptomatic improvement in over 90% of patients. On the basis of our experience, we advocate the use of a highly tailored approach in the selection of redo procedures based on the results of pre-operative oesophageal function testing and oesophagogastroscopy.

	Acknowledgments

 
The authors gratefully acknowledge the contribution of Mr F. Salama in the management of these patients.

	Footnotes

 
Presented at the 10th Annual Meeting of the European Society of Thoracic Surgeons, Istanbul, Turkey, October 26–28, 2002.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): George Kanellopoulos Mark L. Field John P. Duffy Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Khan, O. A. Articles by Duffy, J. P. Search for Related Content PubMed PubMed Citation Articles by Khan, O. A. Articles by Duffy, J. P. Related Collections Esophagus - other