Department of Surgery, Division of GI Surgery and Transplantation, Hôpital Saint Eloi, CHU-Montpellier, France.
Department of Surgery, Division of GI Surgery and Transplantation, Hôpital Saint Eloi, CHU-Montpellier, France.
Int J Surg. 2020 Apr;76:121-127. doi: 10.1016/j.ijsu.2020.03.004. Epub 2020 Mar 10.
Short and long-term outcomes after repeat anti-reflux surgery (RARS) are still debated and generally not considered as satisfying as after primary anti-reflux surgery (PARS). The aim of this study was to evaluate functional outcomes after RARS and risk factors associated to intra-operative and post-operative complications.
This is a multicenter retrospective survey from four European laparoscopic centers. Patients who underwent elective RARS from January 2005 to October 2017 for dysphagia or for persistent reflux disease refractory to medical treatment were analyzed. Data on demographic characteristics, including type and timing of previous operations as well as intra-operative details (surgical technique, type of RARS, conversion to open surgery, prosthetic material placement) were collected. Patients who underwent operations in the emergency setting, interventions mixed with bariatric procedures and PARS performed in other surgical departments were not included in this study. Primary endpoint of this study was to evaluate risk factors associated with intraoperative and postoperative complications. Secondary endpoint was to evaluate clinical outcomes and to identify any possible correlation with clinical and surgical parameters.
Among 1662 patients who underwent PARS, failure occurred in 174 (10.5%) patients. Repeat surgery was performed in 117 (7%) patients, after a mean time of 80 months (range 4-315). RARS was carried out laparoscopically in 88% of cases. Prosthetic mesh to reinforce hiatoplasty was used in 22.2% of patients. Intra-operative upper gastro-intestinal tract's injuries occurred in 6 (5.1%) patients. Perioperative mortality was nil and 13 (11.1%) patients experienced postoperative complications. Mean length of hospital stay was 9.6 ± 6.4 days. Based on a multivariable analysis, age >70 years (OR 1.074, C.I.95% 1.018-1.133, p = 0.008) and body mass index (BMI) < 23 (OR 0.172, C.I.95% 0.052-0.568, p = 0.004) were independently associated to postoperative complications. After a mean follow-up time of 36 months (range 6-107), 24 (20.5%) patients presented recurrent symptoms. Based on a multivariable analysis, early onset of dysphagia (OR 3.539, C.I.95% 1.254-9.990, p = 0.017), open approach (OR 4.505, C.I.95% 1.314-15.442, p = 0.016) and the use of prosthetic material (OR 2.790, C.I.95% 0.930-8.776, p = 0.047) were significantly associated to good clinical outcomes.
Repeat anti-reflux surgery is a safe and feasible procedure in high-volume centers, with acceptable perioperative outcomes. Long-term results are favorable with a success rate of almost 80%. Advanced age (>70 years) and low BMI (<23 kg/m) were factor predicting perioperative complications. The use of prosthesis for hiatoplasty was associated to better functional outcomes.
重复抗反流手术（RARS）的短期和长期效果仍存在争议，一般不如初次抗反流手术（PARS）满意。本研究旨在评估 RARS 后的功能结果，并确定与术中及术后并发症相关的危险因素。
这是来自欧洲四个腹腔镜中心的一项多中心回顾性调查。分析了 2005 年 1 月至 2017 年 10 月间因吞咽困难或药物治疗无效的持续性反流性疾病而行择期 RARS 的患者。收集了人口统计学特征的数据，包括以前手术的类型和时间以及术中细节（手术技术、RARS 类型、转为开放手术、假体材料放置）。本研究不包括在急诊情况下进行的手术、与减肥手术混合的干预措施以及其他外科部门进行的 PARS。本研究的主要终点是评估与术中及术后并发症相关的危险因素。次要终点是评估临床结果，并确定与临床和手术参数的任何可能相关性。
在 1662 例行 PARS 的患者中，174 例（10.5%）患者出现失败。在平均 80 个月（4-315 个月）后，117 例（7%）患者行重复手术。88%的病例采用腹腔镜进行 RARS。22.2%的患者使用了假体网片来加强横膈膜成形术。术中发生上消化道损伤 6 例（5.1%）。围手术期无死亡，13 例（11.1%）患者发生术后并发症。平均住院时间为 9.6±6.4 天。基于多变量分析，年龄>70 岁（OR 1.074，95%CI 1.018-1.133，p=0.008）和 BMI<23（OR 0.172，95%CI 0.052-0.568，p=0.004）与术后并发症独立相关。在平均 36 个月（6-107 个月）的随访后，24 例（20.5%）患者出现复发症状。基于多变量分析，早期出现吞咽困难（OR 3.539，95%CI 1.254-9.990，p=0.017）、开放手术（OR 4.505，95%CI 1.314-15.442，p=0.016）和使用假体材料（OR 2.790，95%CI 0.930-8.776，p=0.047）与良好的临床结果显著相关。
在高容量中心，重复抗反流手术是一种安全可行的手术，具有可接受的围手术期结果。长期结果良好，成功率接近 80%。高龄（>70 岁）和低 BMI（<23kg/m）是预测围手术期并发症的因素。使用假体进行横膈膜成形术与更好的功能结果相关。
