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Third-time (“redo–redo”) anti-reflux surgery: patient-reported outcomes after a thoracoabdominal approach

  • 2019 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Approximately 3–6% of patients undergoing anti-reflux surgery require “redo” surgery for persistent gastroesophageal reflux disease (GERD). Further surgery for patients with two failed prior anti-reflux operations is controversial due to the morbidity of reoperation and poor outcomes. We examined our experience with surgical revision of patients with at least two failed anti-reflux operations.

Methods

Adults undergoing at least a second-time revision anti-reflux surgery between 1999 and 2017 were eligible. The primary outcomes were general and disease-specific quality-of-life (QoL) scores determined by Short-Form-36 (SF36) and GERD-Health-Related QoL (GERD-HRQL) instruments, respectively. Secondary outcomes included perioperative morbidity and mortality.

Results

Eighteen patients undergoing redo–redo surgery (13 with 2 prior operations, 5 with 3 prior operations) were followed for a median of 6 years [IQR 3, 12]. Sixteen patients (89%) underwent open revisions (14 thoracoabdominal, 2 laparotomy) and two patients had laparoscopic revisions. Indications for surgery included reflux (10 patients), regurgitation (5 patients), and dysphagia (3 patients). Intraoperative findings were mediastinal wrap herniation (9 patients), misplaced wrap (2 patients), mesh erosion (1 patient), or scarring/stricture (6 patients). Procedures performed included Collis gastroplasty + fundoplication (6 patients), redo fundoplication (5 patients), esophagogastrectomy (4 patients), and primary hiatal closure (3 patients). There were no deaths and 13/18 patients (72%) had no postoperative complications. Ten patients completed QoL surveys; 8 reported resolution of reflux, 6 reported resolution of regurgitation, while 4 remained on proton-pump inhibitors (PPI). Mean SF36 scores (± standard deviation) in the study cohort in the eight QoL domains were as follows: physical functioning (79.5 [± 19.9]), physical role limitations (52.5 [± 46.3]), emotional role limitations (83.3 [± 36.1]), vitality (60.0 [± 22.7]), emotional well-being (88.4 [± 8.7]), social functioning (75.2 [± 31.0]), pain (66.2 [± 30.9]), and general health (55.0 [± 39.0]).

Conclusion

An open thoracoabdominal approach in appropriately selected patients needing third-time anti-reflux surgery carries low morbidity and provides excellent results as reflected in QoL scores.

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Author information

Authors and Affiliations

  1. Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA, 02114, USA

    Nikhil Panda

  2. Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA

    David W. Rattner

  3. Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA

    Christopher R. Morse

Authors
  1. Nikhil Panda
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  2. David W. Rattner
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  3. Christopher R. Morse
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Corresponding author

Correspondence to Nikhil Panda.

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Disclosures

Dr. Nikhil Panda is supported through the NIH T32 DK007754-18 (Research Training in Alimentary Tract Surgery) training grant. Dr. Christopher Morse has a consulting agreement with Olympus. Dr. David Rattner has a consulting agreement with Olympus.

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Appendix: GERD-Health Related Quality of Lift Questionnaire (GERD-HRQL) administered to patients in this study. Questions 1–9 were used to determine the “modified GERD-HRQL,” reported in a prior study by our research group [12]

Appendix: GERD-Health Related Quality of Lift Questionnaire (GERD-HRQL) administered to patients in this study. Questions 1–9 were used to determine the “modified GERD-HRQL,” reported in a prior study by our research group [12]

[] On PPIs     [] Off PPIs     If off, for how long? ____________ (days/months)

  • Scale for following questions:

  • 0: no symptom

  • 1: symptoms noticeable but not bothersome

  • 2: symptoms noticeable and bothersome but not every day

  • 3: symptoms bothersome every day

  • 4: symptoms affect daily activity

  • 5: symptoms are incapacitating to do daily activities

    1. 1.

      How bad is the heartburn?

    2. 2.

      Heartburn when lying down?

    3. 3.

      Heartburn when standing up?

    4. 4.

      Heartburn after meals?

    5. 5.

      Does heartburn change your diet?

    6. 6.

      Does heartburn wake you from sleep?

    7. 7.

      Do you have difficulty swallowing?

    8. 8.

      Do you have pain with swallowing?

    9. 9.

      If you take medication, does this affect your daily life?

    10. 10.

      How bad is the regurgitation?

    11. 11.

      Regurgitation when lying down?

    12. 12.

      Regurgitation when standing up?

    13. 13.

      Regurgitation after meals?

    14. 14.

      Does regurgitation change your diet?

    15. 15.

      Does regurgitation wake you from sleep?

    16. 16.

      How satisfied are you with your present condition?

      • [] Satisfied

      • [] Neutral

      • [] Dissatisfied

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Panda, N., Rattner, D.W. & Morse, C.R. Third-time (“redo–redo”) anti-reflux surgery: patient-reported outcomes after a thoracoabdominal approach. Surg Endosc 34, 3092–3101 (2020). https://doi.org/10.1007/s00464-019-07059-4

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  • DOI: https://doi.org/10.1007/s00464-019-07059-4

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