Is laparoscopic reoperation for failed antireflux surgery feasible?

Hypothesis: Laparoscopic techniques can be used to treat patients whose ant ireflux surgery has failed. Design: Case series. Setting: Two academic medical centers. Patients: Forty-six consecutive patients, of whom 21 were male and 25 were female (mean age, 55.6 years; range, 15-80 years). Previous antireflux proc edures were laparoscopic (21 patients), laparotomy (21 patients), thoracoto my (3 patients), and thoracoscopy (1 patient). Main Outcome Measures: The cause of failure, operative and postoperative mo rbidity, and the level of follow-up satisfaction were determined for all pa tients. Results: The causes of failure were hiatal herniation (31 patients [67%]), fundoplication breakdown (20 patients [43%]), fundoplication slippage (9 pa tients [20%]), tight fundoplication (5 patients [11%]), misdiagnosed achala sia (2 patients [4%]), and displaced Angelchik prosthesis (2 patients [4%]) . Twenty-two patients (48%) had more than 1 cause. Laparoscopic reoperative procedures were Nissen fundoplication (n = 22), Toupet fundoplication (n = 13), paraesophageal hernia repair (n = 4), Dor procedure in = 2), Angelchi k prosthesis removal (n = 2), Heller myotomy (n = 2), and the takedown of a wrap (n = 1). In addition, 18 patients required crural repair and 13 requi red paraesophageal hernia repair. The mean +/- SEM duration of surgery was 3.5 +/- 1.1 hours. Operative complications were fundus tear (n = 8), signif icant bleeding in = 4), bougie perforation (n = 1), small bowel enterotomy (n = 1), and tension pneumothorax (n = 1). The conversion rate (from laparo scopic to an open procedure) was 20% overall (9 patients) but 0% in the las t 10 patients. Mortality was 0%. The mean +/- SEM hospital stay was 2.3 +/- 0.9 days for operations completed laparoscopically. Follow-up was possible in 35 patients (76%) at 17.2 +/- 11.8 months. The well-being score (1 best ; 10, worst) was 8.6 +/- 2.1 before and 2.9 +/- 2.4 after surgery (P < .001 ). Thirty-one (89%) of 35 patients were satisfied with their decision to ha ve reoperation. Conclusions: Antireflux surgery failures are most commonly associated with hiatal herniation, followed by the breakdown of the fundoplication. The lap aroscopic approach may be used successfully to treat patients with failed a ntireflux operations. Good results were achieved despite the technical diff iculty of the procedures.