Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA, 02114, USA.
Division of General and Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
Surg Endosc. 2020 Jul;34(7):3092-3101. doi: 10.1007/s00464-019-07059-4. Epub 2019 Aug 6.
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.
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.
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]).
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.
约 3-6%接受抗反流手术的患者需要为持续性胃食管反流病（GERD）进行“翻修”手术。由于再次手术的发病率和不良结局，对于两次抗反流手术失败的患者进一步手术存在争议。我们检查了我们对至少两次抗反流手术失败的患者进行手术修正的经验。
1999 年至 2017 年间接受至少第二次修正性抗反流手术的成年人符合条件。主要结局是通过短表 36（SF36）和胃食管反流病相关生活质量（GERD-HRQL）量表分别确定的一般和疾病特异性生活质量（QoL）评分。次要结局包括围手术期发病率和死亡率。
18 名接受 redo-redo 手术的患者（13 名有 2 次手术，5 名有 3 次手术）接受了中位数为 6 年（IQR 3, 12）的随访。16 名患者（89%）接受了开放性修正术（14 例胸腹联合，2 例剖腹），2 名患者接受了腹腔镜修正术。手术指征包括反流（10 例）、反流（5 例）和吞咽困难（3 例）。术中发现纵隔包裹疝（9 例）、包裹位置不当（2 例）、网片侵蚀（1 例）或瘢痕/狭窄（6 例）。手术包括 Collis 胃成形术+胃底折叠术（6 例）、再次胃底折叠术（5 例）、食管胃切除术（4 例）和原发性食管裂孔疝修补术（3 例）。无死亡病例，18 例患者中有 13 例（72%）无术后并发症。10 名患者完成了 QoL 调查；8 名报告反流缓解，6 名报告反流缓解，4 名仍在服用质子泵抑制剂（PPI）。研究队列中 QoL 领域的 SF36 评分（±标准差）如下：身体功能（79.5 [±19.9]）、身体角色受限（52.5 [±46.3]）、情绪角色受限（83.3 [±36.1]）、活力（60.0 [±22.7]）、情绪健康（88.4 [±8.7]）、社会功能（75.2 [±31.0]）、疼痛（66.2 [±30.9]）和一般健康（55.0 [±39.0]）。
在需要第三次抗反流手术的适当选择的患者中，采用开胸腹方法，发病率低，生活质量评分反映出结果极佳。
