Overview
Definition:
Revisional fundoplication refers to a surgical procedure performed to correct or improve upon a previously failed anti-reflux surgery, most commonly a Nissen fundoplication
It aims to re-establish adequate gastroesophageal sphincter function and relieve persistent or recurrent symptoms of gastroesophageal reflux disease (GERD).
Epidemiology:
Failure rates for primary Nissen fundoplication range from 1% to 10%, necessitating reoperation in a subset of patients
Factors contributing to failure include technical errors, patient factors, and disease progression
The incidence of revisional surgery is lower but significant for the management of complex GERD patients.
Clinical Significance:
Failed anti-reflux surgery can lead to debilitating symptoms of GERD, dysphagia, gas bloat, and even nutritional deficiencies
Successful revisional surgery is crucial for improving patient quality of life, preventing long-term complications of GERD, and addressing the reasons for initial failure, making it a vital skill for surgical residents preparing for DNB and NEET SS examinations.
Indications For Reoperation
Persistent Gerd Symptoms:
Recurrence of heartburn, regurgitation, or chest pain despite initial surgery.
Dysphagia Or Odynophagia:
Difficulty or pain with swallowing, often indicating a tight wrap or esophageal dysmotility.
Gas Bloat Syndrome:
Significant abdominal bloating, early satiety, and inability to belch, often due to an overly tight wrap.
Hernia Recurrence:
Recurrence of a paraesophageal or sliding hiatal hernia after initial repair.
Suture Dehiscence Or Wrap Migration:
Mechanical failure of the original fundoplication wrap.
Incidental Findings:
Discovery of other pathology during investigation for persistent symptoms, such as malignancy.
Diagnostic Approach
History Taking:
Detailed history is paramount: precise nature of symptoms (heartburn, regurgitation, dysphagia, bloating), timeline of symptom onset and progression, previous surgical details (date, surgeon, type of procedure), dietary habits, and response to medical management.
Physical Examination:
General physical examination
Abdominal examination for tenderness, masses, or distension
Assess for any signs of malnutrition or dehydration.
Investigations:
Esophagogastroduodenoscopy (EGD) with biopsies to assess the wrap integrity, rule out complications like strictures or Barrett's esophagus
Esophageal manometry to evaluate esophageal motility and resting LES pressure
24-hour pH monitoring or pH-Impedance study to objectively confirm reflux
Barium swallow or CT scan to assess for hernia recurrence or anatomical abnormalities.
Differential Diagnosis:
Non-ulcer dyspepsia, functional heartburn, biliary colic, peptic ulcer disease, achalasia, eosinophilic esophagitis, cardiac ischemia, anxiety disorders
Differentiating from these is key to appropriate management planning.
Surgical Management Options
Re-do Nissen Fundoplication:
Full re-dissection and creation of a new 360-degree wrap, typically performed laparoscopically
This is challenging due to adhesions and scar tissue.
Partial Fundoplication:
Creation of a partial wrap (e.g., Toupet 270-degree posterior fundoplication or Dor 180-degree anterior fundoplication) to reduce the risk of dysphagia and gas bloat.
Hernia Repair With Fundoplication:
If a hiatal hernia has recurred, simultaneous repair of the hernia with a fundoplication is necessary, often with mesh reinforcement.
Other Procedures:
In cases of severe dysmotility or failed wrap unresponsive to revision, alternative procedures like magnetic sphincter augmentation (LINX) or esophageal lengthening procedures may be considered.
Preoperative Preparation
Patient Counseling:
Thorough discussion of risks, benefits, and potential outcomes, including the possibility of persistent symptoms or new complications
Setting realistic expectations is vital.
Optimization Of Medical Condition:
Addressing any malnutrition or anemia
Optimization of pulmonary function if indicated.
Bowel Preparation:
Standard bowel preparation protocols for elective abdominal surgery
Prophylactic antibiotics are administered.
Anesthesia Considerations:
Careful anesthetic management is required due to potential airway issues and the need for muscle relaxation to facilitate dissection
Intraoperative endoscopy may be used to assess the wrap.
Postoperative Care And Follow Up
Pain Management:
Adequate analgesia, often multimodal
Early mobilization to prevent deep vein thrombosis and pulmonary complications.
Dietary Advancement:
Gradual progression from clear liquids to a soft diet, then to a regular diet as tolerated
Emphasis on small, frequent meals and avoiding gas-producing foods.
Monitoring For Complications:
Close monitoring for bleeding, infection, leaks, dysphagia, and gas bloat
Nasogastric tube may be used initially for decompression.
Long Term Follow Up:
Regular follow-up appointments with the surgeon to assess symptom resolution, functional status, and nutritional intake
Repeat investigations as needed to monitor for recurrence or complications.
Complications
Early Complications:
Bleeding, infection, intra-abdominal abscess, wound complications, injury to adjacent organs (spleen, esophagus, stomach), pneumothorax, DVT/PE, early dysphagia, nausea, vomiting.
Late Complications:
Recurrent GERD, persistent dysphagia, gas bloat syndrome, wrap dehiscence or migration, hiatal hernia recurrence, malnutrition, gastric outlet obstruction.
Prevention Strategies:
Meticulous surgical technique, avoiding excessive tension on the wrap, accurate identification of anatomical structures, appropriate patient selection, careful preoperative assessment of esophageal motility, and comprehensive postoperative management.
Key Points
Exam Focus:
Understanding the common reasons for Nissen failure and the principles of revisional surgery
Differentiating between wrap failure, hernia recurrence, and motility disorders
Key diagnostic modalities (manometry, pH monitoring)
Surgical approaches (partial vs
full wraps)
Management of dysphagia and gas bloat.
Clinical Pearls:
Always suspect a motility disorder in patients with severe dysphagia post-fundoplication
Intraoperative endoscopy is invaluable for assessing wrap tension
A partial wrap (Toupet or Dor) is often favored in revisional surgery to minimize dysphagia
Meticulous dissection is crucial due to dense adhesions.
Common Mistakes:
Inadequate preoperative workup leading to misdiagnosis or inappropriate surgical choice
Overly aggressive dissection leading to injury of surrounding structures
Creation of a too-tight wrap, exacerbating dysphagia and gas bloat
Failing to address a recurrent hiatal hernia
Insufficient long-term follow-up leading to missed recurrences or complications.