Puri Ruchir, Smith C Daniel, Bowers Steven P
1 Department of Surgery, University of Florida , Jacksonville, Florida.
2 Esophageal Institute of Atlanta , Atlanta, Georgia .
J Laparoendosc Adv Surg Tech A. 2018 Sep;28(9):1089-1093. doi: 10.1089/lap.2018.0063. Epub 2018 May 16.
To evaluate outcomes of surgical remediation for symptomatic or anatomic failure after a transoral incisionless fundoplication (TIF).
This retrospective study was performed on 11 patients who underwent a remedial operation following TIF failure between June 2011 and September 2016 at the Mayo Clinic in Florida for persistent foregut symptoms. Upper gastrointestinal workup characterized 1 patient as having normal post-TIF anatomy and 10 as having anatomic failure. Ambulatory pH testing was performed in 7 patients and was abnormal in all. All patients underwent a laparoscopic takedown of the prior endoscopic fundoplication and removal of all accessible polypropylene T-fasteners.
All patients had esophageal salvage and have not required a reoperation. Anatomical findings included hiatal hernia (7), esophageal diverticulum (2), hiatal mesh erosion of esophagus (1), long-segment esophageal stricture (1), and normal anatomy (1). Remedial operations included laparoscopic explant of fasteners in all patients with conversion to fundoplication (7), resection/imbrication of esophageal diverticulum (2), Heller myotomy (1), and mesh explant and complex esophageal repair (1). Mean operative time was 177 minutes and median length of stay 3 days (range 2-13 days). At mean follow-up of 10.7 months (range 1-42 months), 7 patients had persistent complaints. Esophagogastroduodenoscopy was repeated in these 7 patients and was normal (n = 3), mild stenosis requiring dilation (n = 2), Los Angeles grade B esophagitis (n = 1), and Barrett's esophagus (n = 1).
Anatomic distortion of the distal esophagus after TIF can be significant, making subsequent operations complex. After remedial surgery, few patients will continue to have troublesome symptoms such as dysphagia.
评估经口无切口胃底折叠术（TIF）后出现症状或解剖结构失败的手术补救效果。
对2011年6月至2016年9月间在佛罗里达州梅奥诊所因持续前肠症状在TIF失败后接受补救手术的11例患者进行了这项回顾性研究。上消化道检查显示，1例患者TIF术后解剖结构正常，10例存在解剖结构失败。7例患者进行了动态pH测试，结果均异常。所有患者均接受了腹腔镜下拆除先前的内镜胃底折叠术并移除所有可触及的聚丙烯T形钉。
所有患者食管均得以挽救，无需再次手术。解剖学发现包括食管裂孔疝（7例）、食管憩室（2例）、食管裂孔网片侵蚀（1例）、长段食管狭窄（1例）和解剖结构正常（1例）。补救手术包括所有患者的腹腔镜下拆除T形钉并改行胃底折叠术（7例）、食管憩室切除/重叠术（2例）、Heller肌切开术（1例）以及网片拆除和复杂食管修复术（1例）。平均手术时间为177分钟，中位住院时间为3天（范围2 - 13天）。平均随访10.7个月（范围1 - 42个月）时，7例患者仍有持续不适。对这7例患者再次进行了食管胃十二指肠镜检查，结果正常（3例）、轻度狭窄需要扩张（2例）、洛杉矶分级B级食管炎（1例）和巴雷特食管（1例）。
TIF术后食管远端的解剖结构扭曲可能很严重，使后续手术变得复杂。补救手术后，很少有患者会继续出现吞咽困难等麻烦症状。
