Management of Failed Fundoplications, End-Stage Gastroesophageal Reflux Disease, and Scleroderma

Outcomes After Fundoplication

Laparoscopic Nissen fundoplication was introduced in 1991 and has become the standard approach to the surgical management of GERD. Variations on the 360-degree fundoplication—including the Hill repair, 180-degree anterior Dor fundoplication, and the 270-degree posterior Toupet fundoplication—are also commonly performed. Transthoracic fundoplication (e.g., the Belsey Mark IV fundoplication) has become increasingly uncommon as a primary antireflux procedure. Several large series have examined long-term outcomes following laparoscopic antireflux surgery. Although enthusiasts claim that 90% of patients experience durable symptom relief and improvement in quality of life, nonsurgical series generally report that 20% to 50% of patients undergoing antireflux operations require ongoing medical therapy. Many patients who resume PPIs have nonreflux-related causes for their symptoms ; it is therefore more accurate to state that between 75% and 80% of patients undergoing primary antireflux surgery will have no further pathologic acid reflux, as documented by pH probe testing, for the remainder of their life span. Many patients who experience mild recurrent heartburn can be managed medically, but between 3% and 6% will ultimately require reoperation. Interestingly, failures do not always occur in the early postoperative period but rather increase in incidence over time; the occasional patient will experience early improvement but ultimately experience failure of fundoplication a decade or more later.

In patients presenting for reoperation after failed antireflux surgery the most common complaint is recurrent heartburn or regurgitation. These symptoms are present in 60% of patients with failed fundoplications. Dysphagia as a dominant symptom is present in 30% of patients. Other complaints include hiatal hernia, gas bloat, and atypical symptoms such as chest or abdominal pain. Often a combination of symptoms is present, making it difficult to distinguish anatomic and functional reasons for failure.

Why Do Fundoplications Fail?

It is important for the foregut surgeon to understand how and why fundoplications fail. In addition to guiding the surgeon away from similar failures in their own practice, this understanding allows the surgeon to put the signs and symptoms of the “failed” patient into context. An educated assessment about the need and strategy for further operations follows. Generally speaking, fundoplications fail because of patient factors that existed prior to surgery, technical problems that lead to compromise of the operation, or early postoperative coughing or retching.

When failure is attributed to patient factors, it can be reasonably said that the preoperative assessment of the patient was inadequate, data gathered during that assessment were misinterpreted, or that poor judgment was used in developing a surgical strategy. Alternatively, the patient may experience progression of a condition that was present but insignificant prior to surgery, such as deterioration in esophageal peristalsis. The ideal patient for antireflux surgery is a nonobese individual with relatively preserved esophageal peristalsis, documented abnormal pH testing with good symptom correlation, typical symptoms of GERD, and symptoms that are at least partially responsive to PPIs. Patients with concomitant esophageal motility disorder (such as achalasia or diffuse esophageal spasm), those in whom obesity contributes to reflux, and those with nonacid reflux or atypical symptoms including laryngospasm, chest pain, and recurrent aspiration have demonstrably inferior outcomes following fundoplication. Similarly, those with overlooked anatomic or functional abnormalities, such as esophageal strictures, fistula, or delayed gastric emptying, are unlikely to have their symptoms relieved by fundoplication alone. Advanced age, female gender, and the presence of a large hiatal hernia have also been noted as potential risk factors for failure.

Technical failures of fundoplication have been well described and may compromise the early technical success of the operation or the durability of the repair. A typical fundoplication involves restoring the gastroesophageal junction and several centimeters of esophagus to an intraabdominal position, construction of a tension-free, “floppy” fundoplication wrap composed of the gastric fundus around a short segment of the intraabdominal esophagus, and securing the wrap and closure of the diaphragmatic crura with permanent suture. Variation exists with regard to the type of fundoplication performed, the need for division of the short gastric arteries, and the use of bioprosthetic mesh to reinforce the closure of the hiatus. Studies by Awais, Dallemagne, Khajanchee, Furnée found that migration of fundoplication wrap was the most common anatomic defect encountered at the time of reoperation, occurring in approximately two-thirds of patients ( Table 23.1 ). Several types of wrap migration can occur, including transhiatal herniation of an intact wrap into the mediastinum or herniation of the proximal stomach through the wrap into a supra- or infradiaphragmatic position (i.e., the “slipped” Nissen). Other technical problems encountered at reoperation include a crural closure or wrap that is too tight or too long, a malpositioned or twisted wrap, or complete disruption of the wrap. An important cause of dysfunction after antireflux surgery stems from a failure to recognize or address a shortened esophagus. The importance of thorough mediastinal dissection with restoration of intraabdominal esophagus to the success of antireflux surgery cannot be overstated. Inability to create sufficient intraabdominal esophagus despite this dissection should be addressed with a Collis gastroplasty. Omission of these steps results in a wrap that is improperly situated and is subject to tensile forces that make it prone to transhiatal herniation. Lastly, injury to the vagus nerves probably contributes to some patients' symptoms postfundoplication, particularly if these symptoms can be attributed to poor gastric emptying, diarrhea, or perhaps gas bloat syndrome.

The most dangerous cause of early failure is herniation of the wrap in the immediate postoperative period. This creates an iatrogenic incarcerated hiatal hernia with potential compromise of regional blood flow. An episode of violent coughing or retching with increase in intraabdominal pressure may precede such event. Without prompt intervention, the patient is at risk for necrosis of the stomach leading to significant morbidity or death. If a portion of the stomach becomes infarcted, the reconstruction options are limited by the patient's physiologic condition and the availability of a viable conduit to restore alimentary continuity. A staged repair is sometimes necessary in this circumstance.

Approach to the Patient With a Failed Fundoplication

Many patients with recurrent or new symptoms after antireflux surgery are reluctant to seek the advice of a surgeon because of the perception that surgery has contributed to their situation or has little to offer by way of palliation. Such patients may only present after years of marginally beneficial medical and minimally invasive therapy. Symptoms and secondary sequelae of failed fundoplication may therefore be quite advanced. Evaluation of all patients begins with a careful attempt to understand the circumstances of the prior operation. When available, the patient's preoperative studies and operative report should be reviewed to look for clues as to the nature of the failure. Attention should be paid to similarities and differences between the patient's previous GERD symptoms and their current symptom complex. For example, dysphagia that was present prior to the first operation and remains speaks to a different etiology of failure than dysphagia that developed only after the fundoplication.

Even in a patient with a history and symptoms that strongly suggest a specific reason for failure of fundoplication, it is necessary to obtain objective data prior to proceeding with reoperation. It is recognized that symptoms and objective findings in primary and secondary GERD are imperfectly correlated; however, the information gained from such studies—which include upper gastrointestinal contrast imaging, high-resolution manometry, pH testing, multichannel intraluminal impendance testing, and endoscopy—guides surgical decision making and provides a baseline against which the outcome of reoperation may be measured.

Contrast Imaging

Contrast imaging—traditionally a dynamic barium swallowing study—is essential for all patients with symptoms after fundoplication. A well-situated, intact fundoplication appears as a filling defect of the gastric fundus that is smooth in contour and located mostly anteriorly. The distal esophagus is narrowed slightly as it transverses this defect. A barium swallow in a patient with recurrent symptoms may demonstrate reflux or delayed passage of liquid or tablet-form contrast, suggesting that the wrap is too tight, too long, herniated, or disrupted ( Fig. 23.1 ). Secondary findings of GERD may be present, including strictures and ulcerations. Lastly, dynamic video swallowing studies may provide clues about abnormal esophageal or gastric motility.