Laparoscopic fundoplication failures - Patterns of failure and response tofundoplication revision

Objective To determine rates and mechanisms of failure in 857 consecutive p atients undergoing laparoscopic fundoplication for gastroesophageal reflux disease or paraesophageal hernia (1991-1998), and compare this population w ith 100 consecutive patients undergoing fundoplication revision (laparoscop ic and open) at the authors' institution during the same period. Summary Background Data Gastroesophageal fundoplication performed through a laparotomy or thoracotomy has a failure rate of 9% to 30% and requires rev ision in most of the patients who have recurrent or new foregut symptoms. T he frequency and patterns of failure of laparoscopic fundoplication have no t been well studied. Methods All patients undergoing fundoplication revision were included in th is study. Symptom severity was scored before and after surgery by patients on a 4-point scale. Evaluation of patients included esophagogastroscopy, ba rium swallow, esophageal motility, 24-hour ambulatory pH, and gastric empty ing studies. Statistical analysis was performed with multiple chi-square an alyses, Fisher exact test, and analysis of variance. Results Laparoscopic fundoplication was performed in 758 patients for gastr oesophageal reflux disease and in 99 for paraesophageal hernia. Median foll ow-up was 2.5 years. Thirty-one patients (3.5%) have undergone revision for fundoplication failure, The mechanism of failure was transdiaphragmatic he rniation of the fundoplication in 26 patients (84%), In 40 patients referre d from other institutions, after laparoscopic fundoplication, only 10(25%) had transdiaphragmatic migration (p < 0.01); a slipped or misplaced fundopl ication occurred in 13 patients (32%), and a twisted fundoplication in 12 p atients (30%). The failure mechanisms of open fundoplication (29 patients) followed patterns previously described. Fundoplication revision procedures were initiated laparoscopically in 65 patients, with six conversions (8%). The morbidity rate was 4% in laparoscopic procedures and 9% in open ones, T here was one death, from aspiration and adult respiratory distress syndrome after open fundoplication. A year or more after revision operation, heartburn, chest pain, and dysphag ia were rare or absent in 88%, 78%, and 91%, respectively, after laparoscop ic revision, and were rare or absent in 91%, 83%, and 70%, respectively, af ter open revision, but II patients ultimately required additional operation s for continued or recurrent symptoms, 3 after open revision (17%), and 8 a fter laparoscopic fundoplication (11%). Conclusions Laparoscopic fundoplication failure is infrequent in experience d hands; the rate may be further reduced by extensive esophageal mobilizati on, secure diaphragmatic closure, esophageal lengthening (applied selective ly), and avoidance of events leading to increased intraabdominal pressure. When revision is required, laparoscopic access may be used successfully by the laparoscopically experienced esophageal surgeon.