Anatomic fundoplication failure after laparoscopic antireflux surgery

Objective Anatomic fundoplication failure occurs after antireflux surgery a nd may be more common in the learning curve of laparoscopic antireflux surg ery (LARS). The authors' aims were to assess the incidence, presentation, p recipitating factors, and management of anatomic fundoplication failures af ter LARS. Summary Background Data The advent of LARS has increased the frequency with which antireflux surgery is performed for the treatment of gastroesophagea l reflux disease. Postoperative symptoms frequently occur and may result fr om physiologic abnormalities or anatomic failure of the fundoplication (e.g ., displacement or disruption). Few data exist on the potential causes or b est treatment of anatomic fundoplication failures. Method LARS was performed in 290 patients by one of the authors over a 6-ye ar period. In the first 53 patients (group 1), the short gas trio vessels w ere divided on a selective basis and the diaphragmatic crura were closed on ly when large hiatal hernias were present. In the subsequent 237 patients ( group 2), the crura were always approximated posterior to the short gastric vessels and full fundic mobilization was performed. Clinical postoperative evaluation was performed on a regular basis, with detailed tests of anatom y and physiology when untoward symptoms developed. Postoperative foregut sy mptoms were reported by 26% of the patients, of whom 73% were found to have an intact fundoplication. In 7% of the entire group, anatomic failure of t he fundoplication was demonstrated, with the majority exhibiting intrathora cic migration of the wrap with or without disruption of the fundoplication. New-onset postoperative epigastric or substernal chest pain frequently her alded fundoplication failure. Factors correlated with the development of an atomic fundoplication failure included presence in group 1, early postopera tive vomiting, other diaphragm "stressors," and large hiatal hernias. Repea t operation has been performed in 8 of the 20 patients (40%), with 5 patien ts successfully treated using laparoscopic techniques. Conclusions Anatomic fundoplication failure occurred in 7% of patients unde rgoing LARS, with the majority occurring in patients who underwent surgery during the learning curve. Anatomic failure is associated with technical sh ortcomings, large hiatal hernias, and early postoperative vomiting. Full es ophageal mobilization and meticulous closure of the diaphragmatic crura pos terior to the esophagus should minimize anatomic functional failure after L APS.