Revisional oesophagogastric surgery

Investigations

Where there are recurrent upper GI symptoms or unusual symptoms following hiatal surgery, the following investigations should be considered:

• Obtain the previous operative notes – assess the extent of oesophageal mobilisation; were the vagus nerves identified; were the short gastric vessels divided; was the hiatus closed and, if so, how; was mesh used; type of fundoplication.

• Oesophagogastroscopy – assess for oesophagitis; the position of the oesophagogastric junction (OGJ); on retroflexion the appearance of an intact fundoplication; the site of the hiatus; evidence of HH, which may be obvious or a subtle slip of fundus into the hiatus ( Fig. 13.1 ).

  

• Contrast swallow – assess the anatomy of the lower oesophagus and OGJ; site of the OGJ; flow of contrast; the presence of HH or not; the presence of reflux; delayed gastric emptying ( Fig. 13.2 ).

  

• Computed tomography (CT) scan of the chest and upper abdomen – if a significant recurrent HH is suspected, to define anatomy and exclude other causes.

• Selective manometry – patients with new-onset dysphagia with no cause found or patients with worsening dysphagia, present preoperatively, and who did not have manometry.

• Selective 24-hour pH monitoring – unusual symptoms with normal anatomy and no objective signs of reflux on investigations.

• Radionucleotide gastric emptying studies with solid phase – suspicion of gastroparesis.

From the investigations there should be some clarity with respect to the anatomy of the problem and the ability to match the clinical picture with the investigations. The presence of an anatomical change does not demand surgery. The patient symptoms and the impact on quality of life should be the major consideration when discussing the role of surgery. Having some idea of the pathology offers insights into the potential difficulties, and outcomes, for the patient, which can be discussed prior to considering surgery.

A good classification of the pathophysiology of abnormal hiatal anatomy in patients with recurrent symptoms has been offered by Suppiah et al. and shown in Fig. 13.3 . In that report the reasons for redo surgery were:

• i)

  Wrap intact/hiatus intact – typically dysphagia with fibrosis ± tight hiatus

• ii)

  Wrap disruption only – intact hiatus and intra-abdominal position

• iii)

  ‘Telescope’ or ‘slipped’ fundoplication – the fundoplication has ‘slipped’ onto the cardia such that there is stomach above the wrap ( Fig. 13.3a ).

• iv)

  Para-oesophageal HH – typically lateral (left) to posterior defect with migration of a portion of the fundus into the lower mediastinum. The crura are intact (including the previous posterior suture) but there is a defect. The slip may be small or large ( Fig. 13.3b ).

• v)

  Crural failure with intact wrap – herniation into the lower mediastinum ( Fig. 13.3c ).

• vi)

  Crural failure with wrap disrupted – herniation into the lower mediastinum.

Assessing the pathology with time, the authors found that ‘telescoping’ was the most common problem in the first year. Over subsequent years crural failure with degrees of fundal herniation were more common, likely reflecting the temporal sequence of events that leads to a recurrent hernia.

Hiatal recurrence after repair of a giant HH is common, with one randomised controlled trial reporting a 5-year recurrence, of any size, to be more than 40%. Although the recurrent hernia may increase the risk of symptoms many patients will have no symptoms and those with symptoms are often controlled medically. One study assessed 115 patients without symptoms 6 months and 5 years after a giant HH repair and reported 41 patients to have a hernia, with only two proceeding to revisional surgery. The low rate of revisional surgery for recurrent hernia after giant hiatus hernia repair has been confirmed in a number of studies. ^{, ,}

In spite of the higher rate of recurrent HH after para-oesophageal hernia repair, very few patients require revisional surgery.

Revisional surgery post hiatal surgery for hernia or reflux

Indications for an operation include: upper GI symptoms considered relevant to the previous operation; a correctable disorder defined in the investigations and symptoms affecting quality of life, for which medical therapy does not work or cannot be tolerated. Where the previous surgery was performed through an open approach, the potential for a successful laparoscopic approach is reduced. In spite of this, it is reasonable to approach the first revisional operation laparoscopically, in experienced hands, accepting and counselling the patient that there is a high potential to convert to an open approach. In patients who had a primary laparoscopic approach, the conversion risk is 7–9% ( Table 13.1 ).

The principles are to take the previous operation down, define the pathology, close the hiatus around the oesophagus, and redo a fundoplication. This will entail clearing the adhesions around the cardia, liver, and diaphragm, with definition of both crura of the diaphragm, and then the lower oesophagus, looking for the vagus nerves, with the aim of preservation. Where there was a recurrent HH there is often elongation of the left crus and attenuation of the central tendon anteriorly. This will need repair, typically including an anterior suture. The fundoplication is then performed and fixed to the crura, aiming to reduce migration. There is a school of thought that this group should have mesh supplementation of the hiatal repair. The evidence is mixed, both with respect to the use of mesh, what type of mesh, and where it should be placed and, thus, its use will relate to local preferences and experience.

Specific issues

Dysphagia – if present in the first few weeks consider reoperation. If tight at hiatus, an anterior slit may be required. If no cause is found change to a lesser fundoplication. The use of dilatation has been reported to be successful in selected patients where there is no anatomical defect or mechanical obstruction on investigations. Revision would be reasonable if little or no response to dilatation.

Bloat – Where intractable, and surgery considered reasonable, aim to convert to a lesser fundoplication. The rate of functional symptoms has been shown to be reduced with fundoplications such as anterior 90 degree and 180 degree and in analyses that have compared 270 degree with a 360-degree fundoplication.

Delayed gastric emptying/gastroparesis – symptoms such as anorexia, nausea, dry retching, post-prandial bloat, and colic may indicate this diagnosis, although vomiting may not be a major issue due to the action of the fundoplication. Food present in the stomach after a 6-hour fast suggests a diagnosis of delayed gastric emptying. If early, after the operation, there is the potential for improvement with time. In the longer term, with persistent symptoms the surgical procedures performed to address this diagnosis include pyloroplasty, pyloromyotomy, gastroenterostomy, or distal gastrectomy with either a Billroth II or Roux-en-Y reconstruction. Pyloroplasty/myotomy are the least invasive. Bile reflux gastritis may occur, but is more prevalent following a gastro-enterostomy or Billroth II operations. More recently, there has been the introduction of per-oral endoscopic myotomy of the pylorus – GPOEM. A meta-analysis and systematic review reported equivalent efficacy for this procedure compared with pyloroplasty, with 85% and 84% improvement, respectively, on gastric emptying studies and similar outcomes when the gastroparesis cardinal symptom index score was assessed. GPOEM is not widely performed at this time and requires special expertise.