Reoperative Antireflux Surgery for Failed

Fundoplication: An Analysis of Outcomes in 275

Patients
Omar Awais, DO, James D. Luketich, MD, Matthew J. Schuchert, MD,
Christopher R. Morse, MD, Jonathan Wilson, BS, William E. Gooding, MS,
Rodney J. Landreneau, MD, and Arjun Pennathur, MD
Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, and The University of Pittsburgh Cancer Institute

GENERAL THORACIC
Biostatistics Facility, Pittsburgh, Pennsylvania

Background. With an increase in the performance of 41 (15%). There was no perioperative mortality. At a
laparoscopic antireflux procedures, more patients with a median follow-up of 39.6 months, 31 patients (11.2%) had
failed primary antireflux operation are being referred to a failure of the redo surgery, requiring reoperation. The
thoracic surgeons for complex redo procedures. The ob- two-year estimated probability of freedom from failure
jective of this study was to evaluate our results of redo was 93% (95% confidence interval 89% to 96%). The
antireflux surgery. HRQOL scores, available for 186 patients, were excellent
Methods. We conducted a retrospective review of pa- to satisfactory in 85.5%, and poor in 14.5%.
tients who underwent redo surgery for failed fundopli- Conclusions. Redo antireflux surgery can be performed
cation. The primary endpoint was failure of the redo safely in experienced centers with outcomes that are
operation; other endpoints included gastroesophageal similar to published open results. Complete takedown
reflux disease-health-related quality of life (HRQOL) and reestablishment of the normal anatomy, recognition
after redo fundoplication. of a short esophagus, and proper placement of the wrap
Results. A total of 275 patients (median age, 52 years; are essential components of the procedure. Thoracic
range, 17 to 88 years; men 82, women 193) underwent surgeons with significant laparoscopic and open esoph-
redo antireflux surgery. The most common pattern of ageal surgical experience can perform minimally inva-
failure of the initial operation was transmediastinal mi- sive, complex redo esophageal antireflux procedures
gration-recurrent hernia in 177 patients (64%). Redo sur- safely with good results.
gery included Nissen fundoplication in 200 (73%), Collis (Ann Thorac Surg 2011;92:1083–90)
gastroplasty in 119 (43%), and partial fundoplication in © 2011 by The Society of Thoracic Surgeons

A n increasing number of minimally invasive antire-

flux procedures are being performed and patients
are increasingly being referred to thoracic surgeons for
surgery achieved a satisfactory result and the percentage
of patients with satisfactory results declined to 42% in
patients who had undergone three or more operations.
complex redo operations for failed repairs [1, 2]. The Redo antireflux surgery is a complex operation, and a
failure rates for primary fundoplication range from 2% to thorough evaluation is essential before treatment. One of
30% [3– 8]. Although many patients with mild recurrent our goals in patients with benign esophageal disease is
symptoms can be managed nonoperatively, 3% to 6% of esophageal preservation. There are several options for
primary antireflux procedures will require a reoperative reconstructive antireflux surgery including redo fundo-
intervention [9]. plication and Roux-en-Y near esophagojejunostomy,
In a recent systematic review, approximately one-third which is applicable particularly in obese patients. After
of redo antireflux surgical procedures were performed multiple failed redo operations, esophagectomy may be
laparoscopically [10]. The success rates for either open or the only viable option. The main objective of this study
laparoscopic reoperative surgery, however, are not equal
was to evaluate our experience with reoperative surgery,
to those of primary antireflux operations. Little and
without resection, for failed primary fundoplication. Our
colleagues [3], in an important study, reported that only
primary aim was to evaluate the outcomes after reopera-
84% of patients undergoing open reoperative antireflux
tive antireflux surgery.
Accepted for publication Feb 24, 2011.
Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Material and Methods
Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010.
We retrospectively reviewed our experience with pa-
Address correspondence to Dr Luketich, Department of Cardiothoracic
Surgery, University of Pittsburgh, 200 Lothrop St, Ste C-800, Pittsburgh, tients who underwent reoperative surgery (excluding
PA 15213; e-mail: [email protected]. esophageal resection) at the University of Pittsburgh

© 2011 by The Society of Thoracic Surgeons 0003-4975/$36.00

Published by Elsevier Inc doi:10.1016/j.athoracsur.2011.02.088
 1084 AWAIS ET AL Ann Thorac Surg
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92:1083–90

Medical Center from 1996 to 2008 after failed fundopli-

cation. This study includes a follow-up of our original
series [11] and was approved by our Institutional Review
Board. As this was a retrospective study, individual
patient consent was waived.

Preoperative Evaluation and Investigations

Patients who were candidates for reoperative antireflux
surgery underwent a comprehensive evaluation, with a
complete history and physical examination; investiga-
tions performed included barium esophagram, esopha-
gogastroduodenoscopy, esophageal manometry, pH test-
GENERAL THORACIC

ing, and gastric emptying studies. In addition, the details

of the previous operative procedure were reviewed prior
to the reoperation. Data on preoperative variables, in-
cluding gender, age, symptoms, type of surgery, and the
pattern of failure, were collected. Dysphagia scores were
assessed preoperatively and postoperatively (Table 1).
Fig 1. Construction of the neoesophagus with an endo GIA (gastro-
Surgical Technique
intestinal anastomosing) stapler. (Reprinted from Pierre AF, et al,
Our technique for a minimally invasive approach for Ann Thorac Surg 2002;74:1909 –16 [12], with permission from
redo operations has been detailed previously [11]. In Elsevier.)
brief, an arterial line is used to assess potentially labile
hemodynamics due to a potential pneumothorax that can
occur during the mediastinal dissection. An on-table added. A Collis gastroplasty is performed by making a
endoscopy is performed to assess anatomic abnormali- transgastric window with an end-to-end anastomosis
ties and also to rule out esophageal mucosal lesions, such stapler [12] (Fig 1), and more recently as a wedge gastro-
as high grade dysplasia or cancer, which may change our plasty with a linear stapler [9]. A short, floppy Nissen
operative approach. This is followed by safe port place- fundoplication is constructed over a bougie while the
ment, with the initial port placed by an open technique. crura are approximated primarily. A distal esophageal
Lysis of adhesions is performed systematically and me- myotomy may be considered for patients whose motility
ticulous dissection is commenced towards the hiatus. The studies suggest pseudoachalasia [13]. Finally, our tech-
short gastric vessels are divided, if not done during the nique of Roux-en-Y near esophagojejunostomy, as de-
prior operation. It is important to preserve the perito- scribed previously, can be considered in patients who are
neum covering the crura and preserve the integrity of the obese [14].
crura. Complete right and left crural mobilization are Patients were monitored during visits to the thoracic
essential to hiatal mobilization and eventual primary surgery clinic. The current follow-up schedule in the
closure. The utilization of a mesh can be limited with clinic is two weeks after discharge, every three months
complete crural mobilization and preservation of the for two years, every six months for two additional years,
integrity of the crura. Hiatal dissection is started by and then annually.
staying on the crura, as this will limit intraoperative
perforations and vagal injuries. Finally, the wrap is com- Quality of Life
pletely taken down and the normal anatomy is defined We assessed quality of life by administering the Gastro-
prior to reconstruction. Removal of the gastroesophageal esophageal Reflux Disease-Health-Related Quality of
fat pad, if not done in the prior operation, allows for Life (GERD-HRQOL) questionnaire [15] and the Short
accurate recognition of the gastroesophageal junction; Form 36-Item Health Survey (SF-36). The SF-36 is an
this is important for proper placement of the wrap and to instrument that measures the general health-related
assess the presence of a short esophagus. The esophagus quality of life and is a well-established instrument used
is completely mobilized, including mediastinal mobiliza- in a variety of conditions. The SF-36 estimates both the
tion. If 3 cm of tension-free intraabdominal esophagus is physical and mental components of the quality of life
not achieved, an esophageal lengthening procedure is [16], which are aggregated to two summary measures:
physical component score (PCS) and mental component
score (MCS). The SF-36 transformed summary PCS and
Table 1. Dysphagia Score Scale MCS scores were derived using the Quality Metric soft-
1 ⫽ no dysphagia ware program (Quality Metric, Lincoln, RI). The GERD-
2 ⫽ unable to swallow hard solids HRQOL questionnaire is a disease-specific instrument
3 ⫽ unable to swallow soft solids consisting of nine questions (recently expanded to 10)
4 ⫽ unable to swallow liquids
related to heartburn, regurgitation, dysphagia, diet, and
bloating, with responses from 0 to 5.The best possible
5 ⫽ unable to swallow saliva
score (no symptoms) is 0 and the worst possible score
Ann Thorac Surg AWAIS ET AL 1085
2011;92:1083–90 REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION

(most severe symptoms) is 50 [15]. We classified HRQOL Table 3. Patterns of Failure

scores as excellent (0 –9), satisfactory (10 –15), or poor
Reason for Failure No. (%)
(16 –50) [11].
Mediastinal migration of wrap, 177 (64.4%)
Statistical Design and Analysis hiatal hernia
The primary outcome variable was failure of the redo Short esophagus 119 (43.3%)
procedure requiring reoperation and secondary end- Misplaced wrap 45 (16.4%)
points included the quality of life measures after redo Loose wrap 12 (4.4%)
surgery. Kaplan-Meier plots were constructed using Tight wrap 26 (9.5%)
Greenwood confidence limits for estimation of failure- Disrupted wrap 11 (4%)
free survival. The time-to-failure analysis was performed Not determined 22 (8%)
from the time of the first reoperation performed by our

GENERAL THORACIC
group. In addition, analysis of individual covariates pre-
dictive of failure was performed with the Wald test.
Comparison of dysphagia scores was done by the signed time from the prior operation to the redo operation was
rank test. 36 months.

Patterns of Failure of the Prior Operation and

Results Reoperative Surgery
Patient Characteristics Transmediastinal migration of the wrap or a recurrent
There were 275 patients who underwent surgery for hiatal hernia (177 of 275; 64.4%) was the most common
failed primary fundoplication. Their median age was 52 cause of failure of the prior antireflux operation. Esoph-
years (range, 17 to 88 years). The majority of patients had ageal shortening was noted in 119 patients (119 of 275;
one prior antireflux surgery; 31 patients (11.3%) had more 43.3%) and a defect in the crural repair was identified in
than one prior antireflux procedure. Patient characteris- 12 patients (4.4%) (Table 3).
tics are summarized in Table 2. The most common The most common procedure during reoperation was a
presenting symptoms were heartburn in 63.6% (175 of Nissen fundoplication with or without a Collis gastro-
275), and dysphagia in 49.5% (136 of 275). Other present- plasty (Table 2). The redo procedure was accomplished in
a minimally invasive fashion in 93% of patients (256 of
ing symptoms included regurgitation in 32% (88 of 275),
275; 93%). There were eight conversions to open surgery
and atypical symptoms in 29.5% (81 of 275) of patients.
due to extensive adhesions or a recognized intraopera-
A preoperative upper endoscopy (273 of 275; 99.3%)
tive perforation. Nine operations were started in an open
and contrast swallow evaluation (266 of 275; 96.7%) were
fashion. Mesh was utilized in 22 patients (8%; 22 of 275)
performed in nearly all patients. Upper endoscopy was
as a component of the repair. Major complications in-
abnormal in 82% of patients. Manometry with or without
cluded postoperative leaks, which occurred in 9 patients
pH testing was obtained in 75% of patients (206 of 275).
(3.3%), bleeding in 2 (⬍1%), atrial fibrillation in 6 (2.2%),
Manometry was abnormal in 55% of patients (151 of 275).
pulmonary embolism in 2 (⬍1%), and Clostridium difficile
These tests were not performed when a clear anatomic
colitis in 2 patients (⬍1%). Reexploration was required in
defect was noted on barium contrast swallow or upper
4 patients (1.4%) for complications related to leak or
endoscopic examination. Gastric emptying studies were
bleeding. There was no perioperative mortality. The
obtained more selectively (146 of 275; 53.1%). The median
length of stay ranged from 1 to 75 days with a median
length of stay of 3 days.

Table 2. Patient Characteristics Failure of the Redo Operation

Characteristic No. (%) During follow-up of up to 14.5 years (median follow-up
3.3 years [39.6 months]; interquartile range 1 to 6 years),
Total patients: 275 31 patients (11.3%) had failure of the redo operation
Gender male 82; female 193 requiring surgical intervention. A redo fundoplication
Median age 52 years (range, 17–88 years) was performed in 7 patients, redo fundoplication with
Single redo surgery 244 Collis gastroplasty in 7 patients, a Roux-en-Y esophago-
Multiple redo surgeries 31 jejunostomy in 12 patients, and pyloroplasty in 1 patient.
Type of operation: An esophagectomy was required in 4 patients.
Nissen fundoplication 200 (72.7%) The estimated probability of freedom from failure was
Partial fundoplication 41 (14.9%) 95% at one year (95% confidence interval [CI] 92% to
Collis gastroplasty 119 (43.3%) 97%), 93% at two years (95% CI 89% to 96%), and 84% at
Roux-en-Y 34 (12.4%) five years (95% CI 77% to 88%) (Fig 2). Covariates were
Myotomy 5 (1.8%) analyzed to evaluate association with failure (Table 4).
Additional procedures: Age and partial fundoplication were significantly associ-
Pyloroplasty 9 (3.3%)
ated with failure of the redo operation. There was a trend
for multiple redo operations to be associated with failure.
 1086 AWAIS ET AL Ann Thorac Surg
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92:1083–90

cation have increased due to the dramatic increase in

antireflux surgery in the 1990s [2]. The surgical options
that allow esophageal preservation for recurrent reflux
disease after failed fundoplication include performance
of another fundoplication and the construction of a
Roux-en-Y near esophagojejunostomy. In this series, we
have presented our results of reoperative surgery in 275
patients with a failed antireflux operation and found that
laparoscopic redo antireflux surgery can be performed
safely with outcomes that are similar to published open
results. Recurrence requiring reoperation occurred in
11.3% of patients at a median follow-up of 3.3 years. The
GENERAL THORACIC

estimated probability of freedom from failure was 93% at

two years, and most patients experienced resolution of
dysphagia and a good quality of life after redo antireflux
Fig 2. Kaplan-Meier plot of the probability of failure-free survival. surgery.
Bars are 95% confidence intervals for probability of failure. The classical approach to reoperative antireflux sur-
gery is transthoracic [3, 17, 18]. The potential advantages
Improvement in Symptoms and Quality of Life of a transthoracic approach are its applicability in pa-
tients with multiple prior abdominal operations, “hos-
Paired dysphagia scores were obtained for 135 patients.
tile” abdomen, and when a Belsey fundoplication is
There was a significant decrease in dysphagia after the
chosen by the surgeon. A transabdominal approach fa-
redo procedure. The dysphagia score decreased signifi-
cilitates other intraabdominal procedures (for example,
cantly from 2.7 to 1.4 after redo surgery (signed rank test
p ⬍ 0.0001) (Fig 3). pyloroplasty or Roux-en Y esophagojejunostomy). In a
Routine clinical follow-up was complete in all patients. recent systematic review of patients who underwent
Detailed follow-up with quality of life questionnaires was reoperative surgery after a failed antireflux operation, a
available in 186 patients (68%; 186 of 275). During follow- transabdominal approach was used in approximately
up, the median GERD-HRQOL postoperatively was 5 66% of patients and a transthoracic approach in approx-
(range, 0 to 35). The GERD-HRQOL was excellent in imately 25% [10]. Reports of minimally invasive laparo-
52.2% (97 of 186) of patients, satisfactory in 33.3% (62 of scopic reoperative surgery for failed antireflux proce-
186), and poor in 14.5% (27 of 186) of patients. The general dures are becoming more common [7–11, 19] and our
quality of life was also evaluated with the SF-36 instru- primary approach for redo antireflux procedures is a
ment in a subset of patients. The median PCS was 46.35 laparoscopic approach.
and the mean PCS ⫾ SEM (standard error of the mean)
was 44.38 ⫾ 0.91 (normal ⫽ 50). The median MCS was Clinical Presentation and Evaluation
50.83 and the mean MCS ⫾ SEM was 47.61 ⫾ 0.93 The primary symptoms prompting reoperation reported
(normal ⫽ 50). in the literature are recurrent reflux and dysphagia,
similar to the primary symptoms seen in this series [10].
Dysphagia after primary antireflux surgery can be mul-
Comment tifactorial and includes both anatomic problems with the
Reoperative antireflux surgery presents a challenging repair (tight wrap, long wrap, twisted fundoplication,
problem for surgeons, and referrals for failed fundopli- recurrent hernia) and esophageal dysfunction [13]. In

Table 4. Analysis of Covariates Associated With Failure

Factor Subgroup Hazard Ratio 95% CI p Value

Gender Male Ref

Female 1.75 0.72–4.3 0.212
Age — 0.97 0.95–1.0 0.028
Type of Complete fundoplication (Nissen) Ref
procedure Partial 2.77 1.21–6.36 0.016
fundoplication(Belsey/Dor/Toupet)
Redo 1 Ref
number 2 or 3 2.35 0.96–5.73 0.061
Time to — 0.995 0.99–1.0 0.240
redo
surgery

CI ⫽ confidence interval.
Ann Thorac Surg AWAIS ET AL 1087
2011;92:1083–90 REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION

imately 40% of patients. It is critical to recognize a short

esophagus. If we are unable to achieve 2.5 to 3 cm of
tension-free intraabdominal esophagus after complete
mobilization in the mediastinum, we add a Collis gastro-
plasty to the repair. Some authors have suggested the
routine addition of a Collis gastroplasty after two failures
[7]. Others have not routinely added a Collis gastroplasty
in the management of large hiatal hernias [20]. Maziak
and colleagues [21] reported that they performed a Collis
gastroplasty for short esophagus in 91 of 94 patients with
giant paraesophageal hernia with a very low rate of
recurrent hernia. Similarly, Deschamps and colleagues

GENERAL THORACIC
[18] reported 62.7% utilization of Collis gastroplasty in
their series of reoperative antireflux surgery. In this
series of reoperative surgeries for failed fundoplication,
Fig 3. Frequency histograms of dysphagia scores (A) before (PRE) we used Collis lengthening with extensive esophageal
and (B) after (POST) reoperative antireflux surgery. Lower scores mobilization in 43% of patients.
indicate improved dysphagia. Postoperative scores were significantly Secure crural closure is another important technical
lower (improved) (signed rank p ⬍ 0.0001). factor in reducing the risk of transdiaphragmatic herni-
ation with a recurrent hernia. It is important to preserve
the peritoneal lining covering the crura and preserve the
addition, persistent reflux can cause damage that leads to integrity of the crura. In our series we were able to close
functional and anatomic impairment of the esophagus. the crura primarily in most patients and mesh was used
This, coupled with prior procedures with injury to the sparingly. Another approach that has also been de-
gastroesophageal junction and possible compromise of scribed is the routine use of pledgeted sutures to repair
the integrity of the vagi, adds to the complexities of a the crura in combination with a Collis gastroplasty [22].
redo antireflux operation.
Reoperative antireflux surgery is a complex operation Failure of the Redo Operation
and patients should be comprehensively evaluated prior During a median follow-up of 39.6 months, 11% of the
to consideration for surgery. In particular, a barium patients in this study had failure of the redo procedure
esophagogram and esophagogastroscopy are very useful requiring a reoperation. This is similar to other studies;
and provide a good delineation of the anatomic abnor- Deschamps and colleagues [18] reported that 10.8% of
malities, such as a misplaced wrap or tight wrap, and can patients required reoperation at a median follow-up of 31
rule out esophageal neoplasia, which would require a months. Stirling and Orringer [17] reported that 12 of 73
different approach. These investigations were utilized in patients required another reoperation at a mean fol-
nearly all the patients in our series. Esophageal function low-up of 28 months.
tests (manometry, pH testing) also provide useful infor- The causes for failure of the redo antireflux operation
mation; for example, a patient with recurrent pathologic have been evaluated in few studies [3, 18]. Gender and
reflux who has abnormal peristalsis and contractility with time from prior operation were not significantly associ-
dysphagia may require a partial fundoplication. How- ated with failure of the redo operation in our study and
ever, these tests are not absolutely necessary when there partial fundoplication was significantly associated with
is a clear anatomic defect noted on barium contrast failure of the redo operation. However, a partial fundo-
swallow or upper endoscopic examination, explaining plication was primarily performed in patients with
the patients’ symptoms. In patients with a suspected esophageal dysmotility; therefore, the baseline esopha-
vagal injury, a gastric emptying study should be geal function may, at least in part, be a factor in the
obtained. ultimate outcome. Further work is required to fully
address confounding variables, such as esophageal dys-
Causes of Failure of the Primary Operation function, and the association of the partial wrap with
The most common pattern of failure observed in this failure of the redo operation. We also observed a trend of
series was a transmediastinal migration of wrap, essen- failure of the reoperation with an increasing number of
tially a recurrent hiatal hernia. These findings are con- prior redo antireflux operations, a finding similar to that
sistent with other large reoperative laparoscopic experi- of Little and colleagues [3]. In contrast, Deschamps and
ences [8, 10]. In a systematic review of more than 4,000 colleagues [18] did not find that the number of prior redo
patients, transdiaphragmatic migration of the fundopli- operations was a significant factor in failure. These au-
cation and disruption of the wrap were the most common thors reported that primary obstructive symptoms of
reasons for failure [10]. Factors potentially playing a role dysphagia requiring early dilations may be a marker of
in recurrent hiatal hernia are an unrecognized short long-term failure of a redo operation.
esophagus, creating longitudinal tension on the fundo- The procedure of choice after one or more failed
plication, and the mode of initial diaphragmatic closure. fundoplications depends on many factors and the deci-
In our series, a short esophagus was present in approx- sion should be individualized. We attempt to tailor our
 1088 AWAIS ET AL Ann Thorac Surg
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92:1083–90

approach to the specific patient, based on preoperative normal anatomy, maintaining vagal nerve and crural
testing, clinical symptoms, and intraoperative findings. integrity, recognition of a short esophagus and the
For example, a patient who has an obvious recurrence addition of an esophageal lengthening procedure if
due to the failure to recognize a short esophagus may needed, and the proper construction of the fundopli-
benefit from another attempted repair with the addition cation [9, 25]. Thoracic surgeons with significant lapa-
of a Collis gastroplasty. roscopic and open esophageal surgical experience can
Finally, comorbid conditions should be taken into perform minimally invasive complex redo esophageal
consideration before redo antireflux surgery. Obesity is antireflux procedures safely, with excellent-to-
associated with gastroesophageal reflux [23]. Obese pa- satisfactory results possible in more than 80% of pa-
tients who present with recalcitrant symptoms after an- tients using minimally invasive techniques at an expe-
tireflux surgery can be considered for a Roux-en-Y near rienced center.
esophagojejunostomy [14]. In patients with severe loss of
GENERAL THORACIC

esophageal function, esophagectomy may offer a better

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509 –16. 2290 – 4.
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GENERAL THORACIC
DISCUSSION
DR DANIEL J. BOFFA (New Haven, CT): That was a very nice We did not perform any subset analysis in comparing patient
talk, Omar. satisfaction between those groups.
How many of the patients were done at Pittsburgh primarily,
and are there any tricks that you do during your first operation
DR MARK B. ORRINGER (Ann Arbor, MI): I compliment you
that make redos easier? And how many of the original antireflux
for a well presented paper. Your statement that reoperative
procedures were done open as the first approach?
antireflux surgery is advanced esophageal surgery cannot be
overemphasized. And results such as those you have reported
DR AWAIS: Thank you Dan for your comments. In our ongoing require experience and a large volume of these patients.
analysis, approximately one-third of patients underwent their Despite the unquestioned experience of your group, I am
initial operation elsewhere. concerned about your results. As a Belsey disciple, I recall a
In regards to initial operative approach, about 10% of patients number of us having to “twist Belsey’s arm” to let us report the
had a prior open operation; majority of the patients had lapa- results of the Belsey Mark IV operation, which he did not want
roscopy as their initial approach. to do until he had ten years of follow-up. The abstract of your
Although all redo antireflux operations are challenging, there paper indicates that you have 23 months of mean follow-up in
are some tricks we use to potentially make them easier. Our goal these patients. You already report a nearly 10% incidence of
is always to do it right the first time so that we do not have to need to reoperate, and that is extremely worrisome and por-
reoperate. It all starts with the initial and accurate assessment of tends an unacceptable failure rate. Can you comment upon your
the patient’s symptoms and their correlation with objective tests. relatively high reoperative rate?
We believe long-term success of the original operation depends Further, you use mesh in 24% of your patients. In all the years
on proper diagnosis and indication for the procedure, and that I have performed antireflux-hiatal hernia operations, I have
during the operation, dissection of the hernia sac with reduction
never used mesh at the hiatus. Placing a semi-rigid material
of the hernia, adequate esophageal and crural mobilization with
against an organ that is constantly moving up and down with
preservation of crural lining, recognition of short esophagus, use
diaphragmatic excursions leads to esophagogastric erosion,
of a Collis lengthening when indicated, secure crural closure,
which we are now called upon regularly to treat. Such a
and proper construction of a fundoplication. In our initial
complication is a disaster for the patient and generally leads to
operation we are extremely careful in identifying and preserving
an esophagectomy. I personally believe that there is nothing like
both the anterior vagus and the posterior vagus nerves. We
being able to do these operations open, palpate and grasp the
reflect both nerves off the esophagus in order to place our
tendinous hiatus, and place reliable hiatal sutures that obviate
fundoplication within both nerves. The success of the initial
the need for mesh. Have you experienced such problems with
operation and the reoperation depends on all these factors and
consistently following these steps during our original surgery mesh erosion in your patients?
allows us to avoid a reoperation. Finally, I question the value of manometric data in these
“redo” patients. With a giant paraesophageal hernia and an
accordioned, shortened esophagus, the barium swallow and
DR THOMAS FABIAN (Albany, NY): Omar, congratulations on manometry may show dysmotility. But this does not justify a
a nice presentation. myotomy or partial fundoplication. An esophageal lengthening
What percentage, and I may have missed it, were second-time Collis gastroplasty and Nissen fundoplication straighten the
redos and third-time redos? And if you have that information, esophagus, and the preoperative dysmotility seen on manome-
did you compare patient satisfaction between those groups, and try has little clinical significances.
how did it modify your technical approach to repairing them? Similarly, after several antireflux operations and a partially
obstructed esophagogastric junction, manometry may show dys-
DR AWAIS: Thank you, Tom. In our series, 31 patients under- motility, but the type of fundoplication performed should not be
went two prior operations and very few patients had three or influenced by this. Do you really alter your redo operation based
more. Our approach to all redos regardless of number of prior upon preoperative manometric findings?
operations is the same, that is comprehensive evaluation, and I’d also like to hear your thoughts on the limit of the number
when we reoperate, would be to reestablish normal anatomy, of hiatal hernia-antireflux operations a patient can have before
preserve both vagi, recognize a short esophagus, and reconstruct you say that another fundoplication is destined to failure and a
a new fundoplication. different approach is needed. How many redo laparoscopic
 1090 AWAIS ET AL Ann Thorac Surg
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92:1083–90

repairs are you willing to do? What dictates your decision to do many factors. One, it depends on the patient’s preoperative
something more than just a redo fundoplication? symptoms, such as dysphagia, and some of the objective tests we
I very much enjoyed your paper. use in our evaluation as well as number of redos.
Our goal, always the first time out, is to try to avoid a
DR AWAIS: Thank you, Dr Orringer, for your comments. We reoperative fundoplication but, as you can see, the results are
acknowledge your significant contributions in this field. We not as good, based on many series, as you perform second, third,
almost never use mesh during our initial operation and in this or fourth redo. We see a wide spectrum of patients starting with
series we report mesh utilization in less than 10% of our patients a young patient with obvious anatomic problem, good motility,
in a reoperative setting. I concur that mesh placement at the and normal weight. This patient would obviously be served best
hiatus should be avoided if at all possible and we only reserve its
by a redo fundoplication. In contrast, on the other side of the
utilization in situations in which the crural integrity is destroyed.
spectrum, we may see a patient with multiple redos, severe
I agree with you entirely that these are very complicated
dysmotility, dysphagia, and poor emptying. In such a patient
patients who should be managed at high volume centers for best
esophagectomy may be the best option. In reality, most patients
GENERAL THORACIC

outcomes.
We agree that these outcomes can be better evaluated with present somewhere in between these two extremes and for these
longer follow-up. However, our mean follow-up of 23 months we do not have all the answers. They must be studied exten-
compares well to some of the other, few, large reported series, sively and approached individually. We must tailor the opera-
and some series suggest that most recurrence occur within the tion based on their symptoms, based on their preoperative
first two years. With ongoing follow-up, we have now extended evaluation, and also perhaps BMI [body mass index].
our median duration of follow-up beyond 36 months. We Finally, I would stress during the initial visit all three options,
continue to monitor and follow-up our patients. esophagectomy, fundoplication, and Roux-en-Y are discussed in
And the answer to how many operations you need to do as an detail with the patient, because sometimes you never know what
endpoint for a potential esophagectomy, I think that depends on you will find in the OR.

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© 2011 by The Society of Thoracic Surgeons Ann Thorac Surg 2011;92:1090 • 0003-4975/$36.00
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