What are the causes of re-operations for failed laparoscopic antireflux repair?
J. Boulez (Lyons)
Dallemagne was the promoter of laparoscopic surgery for gastroesophageal reflux.
Currently published studies, reporting monocentric experiments with a perspective of several years validate this approach.
This surgery, like all others, can sometimes fail: the analysis of the causes of failure evidences a certain similarity with open surgery, alongside some differences in terms of the types and frequency of some complications.
Usually, surgical treatment of these failures can be performed by iterative laparoscopy, since the absence of parietal adherences makes reoperation easier to perform [1].
Reoperations concern minor complications or severe complications [2]: they appear either early or late.
The study of the causes of these reoperations is based on our experience with 18 reoperated patients (of which 16 laparoscopic reoperations) and on data from the literature.
Minor complications
Post-surgery hemorrhage justifying reoperation is very rare after laparoscopy: spleen trauma has become a very rare side-effect, as opposed to its frequent occurrence in open surgery. The main cause of this complication is in most cases parietal hemorrhage. Twice, we had to perform an iterative celioscopy to detach and drain the abdominal cavity at the 8th and 10th day of a cure for hiatal hernia with no trace of active hemorrhage. To prevent this complication, a video-assisted visual control should be systematically performed to ensure good parietal hemostasis.
Incisional hernia occured on trocar orifices of 10 mm or bigger that were not subject to a musculo-aponeurotic suture: the weak point is located on the white line and mainly on the sub-umbilical orifice: this complication is very rare compared to its occurrence in open surgery (we have observed it twice in our first 260 treatments for hiatal hernia). Prevention must involve systematic repair of the musculo-aponeurotic defects for all 10 mm trocar orifices.
Major complications
They consist mainly in late complications: dysphagia and recurrence of hiatal hernia and/or reflux. Severe complications occurring early are usually caused by a visceral injury.
Visceral injury
The esophageal wound is the most severe complication: its frequency is difficult to evaluate: 2 cases of reoperations on 758 patients in the French multicentric series [3].
Gastric wound or necrosis can also justify reoperation [4].
Finally, the small intestine wound by blind trauma is a rare and a specific complication of this type of surgery. Most of the time, it is a trauma of the small intestine which occurred outside the camera's range and was not seen.
Residual dysphagia persisting after 3 or 4 months is a complication of laparoscopic surgery, especially at the beginning of the experience
First of all, it can be an error of indication: confusion between the symptoms of achalasia of the LES and reflux, absence of esophageal manometry before surgery. In this context, that we have observed in two cases, where treatment against hiatal hernia with fundoplication especially when it is circular, results in a total functional failure. This complication can be prevented by systematically performing an esophageal manometry before antireflux surgical treatment.
It can also be an error in the choice of process: this example is represented by a reflux in the context of scleroderma: this type of disorder represents a contraindication for circular fundoplication of the Nissen type.
Dysphagia can be caused by an obvious technical defect involving the disposition of the antireflux gastric valve: we have observed this type of complication once: it was a plication performed on the stomach's main part and not on its upper pole, and thanks to laparoscopy, it was possible to perform an actual Nissen procedure after dismantling.
In the absence of an obvious technical defect, dysphagia can be caused by either excessive tightening of the hiatus, or excessive tightening of the gastric valve around the cardia. Such an abnormality was observed mainly at the beginning of our experience, and we had to reoperate four patients in order to treat this kind of complication [5]. The only true prevention of this complication is a perfect mastering of this surgical technique even if the Nissen Rossetti fundoplication increases the risks.
The relapse of hiatal hernia and/or gastroesophageal reflux represents the most frequent cause of failure. It involves two very different aspects, whether this complication occurs very early or late.
The early para-esophageal hernia after surgery with volvulus or gastric strangulation is a complication which seems to be more frequent after laparoscopic approach, even though the exact determinism of this complication has not been clearly evidenced. This complication seems to be favoured by an unclosed hiatus [6]. We observed this complication once in our experience; it requires an emergency reoperation which can sometimes be performed successfully by iterative laparoscopy.
By its frequency and its presentation, late relapse can be compared to that observed after open surgery [1]. This relapse can be favoured by a precocious migration of the valve or by a splipped Nissen procedure. We have treated 7 relapses of hiatal hernias after laparoscopic treatment, 6 of which by iterative laparoscopy with 2 conversions [7].
Our current experience concerns 18 reoperations after antireflux laparoscopic operation:
16 reoperations were performed by an iterative laparoscopic approach with 2 conversions.
Based on this experience, we can say that failures in laparoscopic surgery for reflux are characterized by:
- a very low rate of hemorrhagic and parietal complications compared to open surgery;
- the possible occurrence of a gastric intrathoracic volvulus early after surgery, which is a more frequent complication in laparoscopic surgery;
- by the occurrence of post-surgical dysphagia after Nissen fundoplication; this risk decreases with the surgeon's experience. Laparoscopic reoperation gives excellent long-term results;
- the fact that the technique, when performed rigorously and safely, does not present an increased risk for esophageal or gastric wound;
- by a long-term relapse rate comparable to that of open surgery [1].
Globally, laparoscopy is thus an excellent approach for surgery of gastroesophageal reflux.
References