Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
Piedmont Hospital, Atlanta, GA, USA.
Surg Endosc. 2019 May;33(5):1474-1481. doi: 10.1007/s00464-018-6429-0. Epub 2018 Sep 12.
Outcomes are not well studied in patients undergoing remediation for multi-fundoplication failure, that is, two or more prior failed fundoplications. Re-operation must balance reflux control and restoration of the ability to eat with the challenge of reconstructing a distorted hiatus and GE junction. The purpose of this study is to present our experience with surgical remediation for multi-fundoplication failure.
Medical records were retrospectively reviewed of 91 patients who underwent third time or more esophagogastric operation for fundoplication failure at a single institution from 2007 to 2016. Dysphagia was present in 56% and heartburn in 51%. Median number of prior operations was 2 with range up to 6. Anatomic failure consisted of slipped wrap in 26 cases, wrap herniation in 23, hiatal stenosis in 24, hiatal mesh complication in 8, and wrap dehiscence in 10. Operative approaches generally followed an institutional algorithm and consisted of hiatal hernia repair with: re-do fundoplication in 55%, takedown of fundoplication alone in 24%, Roux-en-Y gastrojejunostomy in 14%, and GE junction resection in 7%. Laparoscopic approach was successful in 81%.
Mean duration of operations was 217 min and median length of stay was 3 days. The complication rate was 13%, with 7% undergoing unplanned early re-operation. Patients were followed for mean 11 months, and recurrent hiatal hernia was detected in 13%. Late re-operation was performed in 6% for recurrent hiatal hernia. Recurrent reflux symptomatology resolved in 93%. Dysphagia resolved in 84%. There were no significant differences in outcomes with regard to number of prior operations, operative approach, BMI, or age.
There is no single best approach to remediation in the multi-fundoplication failure patient. Re-do fundoplication is appropriate in over half of patients. Reoperation for multi-fundoplication failure can be performed via minimally invasive approach with excellent remediation of symptoms, low morbidity, and low recurrence rates.
对于多次胃底折叠术失败（即两次或两次以上先前失败的胃底折叠术）的患者，其结果尚未得到很好的研究。再次手术必须平衡反流控制和恢复进食能力，同时面临重建变形裂孔和胃食管交界处的挑战。本研究的目的是介绍我们在多次胃底折叠术失败的手术修复方面的经验。
回顾性分析了 2007 年至 2016 年期间，一家单机构对 91 例因胃底折叠术失败而接受第三次或更多次食管胃手术的患者的病历。56%的患者存在吞咽困难，51%的患者存在烧心。先前手术的中位数为 2 次，范围为 2 至 6 次。解剖学失败包括 26 例包绕滑脱、23 例包绕疝出、24 例裂孔狭窄、8 例裂孔网片并发症和 10 例包绕裂开。手术方法一般遵循机构算法，包括：再次行胃底折叠术 55%，单纯切开胃底折叠术 24%，Roux-en-Y 胃空肠吻合术 14%，胃食管交界处切除术 7%。腹腔镜方法成功率为 81%。
手术平均时间为 217 分钟，中位住院时间为 3 天。并发症发生率为 13%，7%的患者需要计划外的早期再次手术。患者平均随访 11 个月，发现 13%的患者存在复发性裂孔疝。6%的患者因复发性裂孔疝行晚期再次手术。93%的复发性反流症状得到缓解。84%的吞咽困难得到缓解。在先前手术次数、手术方式、BMI 或年龄方面，结果没有显著差异。
对于多次胃底折叠术失败的患者，没有单一的最佳修复方法。再次行胃底折叠术适用于一半以上的患者。通过微创方法对多次胃底折叠术失败进行再次手术，可以很好地缓解症状，且发病率低，复发率低。
