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The Journal of Thoracic and Cardiovascular Surgery, Vol 91, 511-517, Copyright © 1986 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
AG Little, MK Ferguson and DB Skinner
Experience with gastroesophageal reflux in patients without prior
operations has yielded understanding of pathophysiology, surgical
techniques, and results. Less is known about patients with failed
antireflux operations. This report of 61 patients undergoing repeat
antireflux procedures addresses this issues. Not included are patients with
gastroesophageal reflux after ulcer operations or with inappropriate
antireflux operations for motility disorders. Group A patients (n = 34) had
only one previous operation, Group B (n = 19) had two, and Group C (n = 8)
had three or more. Group C had significantly (p less than 0.05) more
dysphagia and less heartburn than Group A. This observation correlated with
findings from manometry, pH testing, and endoscopy, which showed
progressively worse esophageal body function and a greater incidence of
severe esophagitis and esophageal leak, but less gastroesophageal reflux,
in Group C than B and in Group B compared to A. Operative mortality was
4.9%. Repeat antireflux operations in the 58 survivors were as follows:
Group A included 25 standard antireflux procedures and seven bowel
interpositions, and 75% were transthoracic. Group B included 16 antireflux
procedures and one bowel interposition, and 82% were transthoracic. Group C
included four antireflux procedures and three interpositions, and all were
transthoracic. Clinical results were excellent or good in 85% in Group A,
66% in Group B, and only 42% in Group C (A versus C, p less than 0.05).
Surgical complications increased from 27% in Group A to 75% in Group C (p
less than 0.05). Conclusions: Patients with one prior operation and
recurrent gastroesophageal reflux are similar to patients with no prior
operations. Results of repeat antireflux operations deteriorate with
increasing operations because of impaired esophageal function and
progressive tissue destruction. Therefore, second reoperations must be
definitive and resection and reconstruction with healthy tissue considered.
A transthoracic approach is preferable for first reoperations and mandatory
after multiple antireflux procedures.
ARTICLES
Reoperation for failed antireflux operations
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