Surgical Complications of Laparoscopic Fundoplication for Gastroesophageal Reflux Disease: Call for Reevaluation of Surgical Criteria

Hookman, Perry; Barkin, Jamie S.; Johnson, David
November 2000
American Journal of Gastroenterology;Nov2000, Vol. 95 Issue 11, p3305
Academic Journal
The aim of this study was to assess the incidence, presentation, precipitating factors and management of anatomic fundoplication failure after laparoscopic antireflux surgery (LARS). The patient population consisted of 292 consecutive patients undergoing LARS by Dr. Hookman between May 1992 and August 1998. The patient data was entered prospectively into a computerized database. Preoperative evaluation of all patients included a detailed history assessing global health status and symptoms of gastroesophageal reflux disease (GERD). All patients underwent upper gastrointestinal endoscopy and esophageal manometry. Most patients underwent 24-h pH testing. The patients were divided into two groups based on the date that the LARS technique was performed. In all patients the fundoplication was constructed around a 50-60 F-Maloney dilator. The wrap was approximately 2.5 cm long and created using three sutures of heavy gauge, nonabsorbable suture. Group 1 consisted of the initial 53 patients, all of whom underwent total fundoplications with a mean operative time of 177 ± 9 min. The details of the operative technique were variable, i.e., the cura were reapproximated only if a large defect existed and the short gastric vessels were divided selectively. Group 2 consisted of the other 237 patients. The technique differed from Group t in that the crura was always approximated posteriorly to the esophagus and the short gastric vessels were divided routinely allowing full fundic mobilization. All patients were evaluated as outpatients at 2-4 wk and 6 and 12 months after surgery. Thereafter, they were evaluated annually. Patients completed detailed questionnaires regarding satisfaction, overall quality of life, recurrence of GERD-related symptoms, and occurrence of "diaphragmatic stressors" (e.g., repeated coughing or sneezing, vomiting, motor vehicle accidents, weight-lifting, etc.). Patients who reported unusual abdominal discomfort, GERD-related symptoms, or dysphagia, underwent further diagnostic testing. Although there were no deaths. Grade II or III postoperative complications as outlined by Clavien, et al. (1) occurred in 14 patients (5%) with three patients (1%) requiring a second surgical procedure within 2 wk of the initial surgery. Additionally, early postoperative (approximately 4 wk) esophageal dilatation was required in four patients who had severe dysphagia. The most common symptom to occur postoperatively was transient epigastric or substernal chest pain (56% of the patients). Other symptoms initially experienced were dysphagia (7%), heartburn (5%), and regurgitation (3%). Recurrent GERD despite an intact fundoplication was diagnosed in ten patients (3.4%). Twenty of 292 patients (7%) had anatomic failure of the fundoplication diagnosed by imaging studies. The interval between surgery and the diagnosis of fundoplication failure ranged from 1 day to 60 months with a median of 24 months.


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