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When Fundoplication Fails: Redo?

Smith, C Daniel MD*; McClusky, David A. MD*; Rajad, Murad Abu MD*; Lederman, Andrew B. MD†; Hunter, John G. MD‡

Annals of Surgery:
Original Articles
Abstract

Objective: The largest series in the literature dealing with redo fundoplication was presented and published in 1999 and included 100 patients. Herein we update this initial series of 100, with 207 additional patients who have undergone redo fundoplication (n = 307).

Summary Background Data: Increasing numbers of patients are failing esophagogastric fundoplication and requiring redo procedures. Data regarding the nature of these failures have been scant.

Methods: Data on all patients undergoing foregut surgery are collected prospectively. Between 1991 and 2004, 307 patients underwent redo fundoplication for the management of anatomic complications or recurrent GERD. Statistical analysis was performed with multiple χ2 and Mann-Whitney U analyses, as well as ANOVA.

Results: Between 1991 and 2004, 1892 patients underwent primary fundoplication for GERD (1734) or paraesophageal hernia (158). Of these, 54 required redo fundoplication (2.8%). The majority of failures (73%) were managed within 2 years of the initial operation (P = 0.0001). The mechanism of failure was transdiaphragmatic wrap herniation in 33 of 54 (61%). In the 231 patients who underwent fundoplication elsewhere, 109 had transdiaphragmatic herniation (47%, P = NS). In this group of 285 patients, 22 (8%) required another redo (P = NS). The majority of the procedures were initiated laparoscopically (240/307, 78%), with 20 converted (8%). Overall mortality was 0.3%.

Conclusions: Failure of fundoplication is unusual in experienced hands. Most are managed within 2 years of the initial operation. Wrap herniation has now become the most common mechanism of failure requiring redo. Redo fundoplication was successful in 93% of patients, and most could be safely handled laparoscopically.

In Brief

Fundoplication is widely accepted as the gold standard in operative management of GERD. Failure requiring reoperation is unusual, but when it occurs the outcomes of redo surgery can be quite good. This paper details an experience with 285 patients undergoing 305 redo fundoplications including operative and long-term outcomes.

Author Information

From the *Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; †Surgical Specialists of Western New England, PC, Pittsfield, Massachusetts; and the ‡Department of Surgery, Oregon Health Sciences University, Portland, Oregon.

Reprints: C. Daniel Smith, MD, Department of Surgery, Emory University School of Medicine, 1364 Clifton Road, NE (H124), Atlanta, GA 30322. E-mail: csmit27@emory.edu.

© 2005 Lippincott Williams & Wilkins, Inc.