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Refundoplication for recurrent gastroesophageal reflux

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Abstract

Reoperation after a failed antireflux procedure is a surgical challenge. Many operative techniques have been proposed, but reports on systematic follow-up with endoscopy and esophageal function tests are few. The purpose of the present study was to evaluate the results of repeated fundoplication in cases of recurrent reflux, including assessment of esophageal function. Of the 18 cases of repeat fundoplication performed for recurrent reflux during 1970–1991 at Tampere University Hospital, 15 were evaluated a median of 18 (range 5–152) months after reoperation. Follow-up studies included endoscopy in all and esophageal function tests (esophageal 24-hour pH recording, manometry, and radionuclide transit) in 14 cases. All the patients had defective fundic wrap before reoperation, whereas at follow-up 12 of the 15 wraps were intact. Reflux symptoms were diminished in all 15. Six patients (40%), however, had objective recurrence of reflux (esophagitis or pathologic pH recording). Three of the recurrences were due to slipped fundic wrap, but the others were probably caused by impaired esophageal function. By repeat fundoplication the wrap could be repaired as reliably as in primary operation. Symptomatic outcome and objective results were reasonable. The results were, however, not as good as after primary operation, which was due to more impaired esophageal motility caused by prolonged reflux or repeated surgery (or both).

Résumé

Réopérer un échec de cure de reflux est un véritable défi. Les techniques proposées en sont nombreuses. Les examens endoscopiques et de la fonction oesophagienne font, par contre, souvent défaut dans le suivi. Le but de cette étude a été d'évaluer les résultats de fundoplicature itérative pour reflux gastro-oesophagien récidivant, comprennant des examens de la fonction oesophagienne. Quinze des 18 cas de fundoplicature itérative effectués à l'Hôpital Universitaire Tampere, Finlande, ont été évalués entre 5 et 152 (médiane = 18) mois après réintervention. Les examens de suivi ont été une endoscopie dans tous les cas et une étude fonctionnelle (pH métrie de 24 heures, manométrie et scintigraphie oesophagienne) chez 14 d'entre eux. Tous les patients avaient une fundoplicature défectueuse avant la réintervention. A la date de point, 12 des 15 fundoplicatures itératives étaient intactes. Les symptômes de reflux avaient disparu chez tous les patients. Six patients (40%) avaient des signes objectifs de reflux (oesophagite et/ou pHmétrie pathologique). Trois des récidives étaient en rapport avec un “slipped” Nissen, mais les autres résultats étaient probablement en rapport avec des troubles fonctionnels de l'oesophage. Une fundoplicature est réalisable comme intervention de reprise pour reflux gastroesophagien. Les résultats au plan symptomatique sont satisfaisants. Les résultats fonctionnels, en revanche, ne sont pas aussi bons, probablement en raison de troubles de mobilité oesophagienne secondaires au reflux prolongé et/ou la chirurgie itérative.

Resumen

La reoperación después de un procedimiento antirreflujo fallido constituye un verdadero desafío quirúrgico, y muchas diferentes técnicas operatorias han sido propuestas. Sin embargo, son escasos los informes sobre seguimiento sistemático mediante endoscopia y pruebas de función esofágica. El propósito del presente estudio fue evaluar los resultados de la fundoplicación repetida en casos de reflujo recurrente, incluyendo también la valoración de la función esofágica. Quince de 18 casos de fundoplicación repetida por reflujo recurrente realizada en el Hospital de la Universidad de Tempere en el periodo 1970–1991 fueron evaluados a un promedio de 18 (rango 5–152) meses después de la reoperación. El estudio de seguimiento incluyó endoscopia en todos los casos y pruebas de función esofágica (registro del pH de 24 horas, manometría y tránsito con radionúclidos) en 14. La totalidad de los pacientes presentaba una plicación fúndica defectuosa antes de la reoperación, en tanto que en el seguimiento 12 de 15 de las plicaciones aparecieron intactas. Los síntomas de reflujo disminuyeron en todos los pacientes. Seis pacientes (40%) exhibían, sin embargo, recurrencia objetiva del reflujo (esofagitis y/o registro anormal de pH). Tres de las recurrencias se debieron a deslizamiento de la plicación fúndica, pero los otros fueron muy probablemente causados por función esofágica anormal. La plicación puede ser reparada mediante la refundoplicación de una manera tan eficaz como en la primera operación, y el resultado sintomático, así como los resultados objetivos, fueron razonables. Sin embargo, los resultados no fueron tan buenos como después de la operación primaria. Esto se debió a mayor anormalidad de la motilidad esofágica causada por reflujo prolongado y/o la cirugía repetida.

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Correspondence to Markku E. Luostarinen M.D..

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Luostarinen, M.E., Isolauri, J.O., Koskinen, M.O. et al. Refundoplication for recurrent gastroesophageal reflux. World J. Surg. 17, 587–593 (1993). https://doi.org/10.1007/BF01659115

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Keywords

  • Esophagitis
  • Como
  • Mese
  • Antireflux Procedure
  • Esophageal Function