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• No financial or other relationship with any product or treatment discussed in this talk

Conflict of Interest / Disclosure

Re-Operations for Failed Anti-Reflux and Failed PEH Procedures

C. Daniel Smith

SSAT MOC CourseThe Surgeon in the Management of

Gastric & Esophageal Diseases

May 7, 2011Chicago, Illinois

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ARS & PEH – Failure Happens

• Anti-reflux Surgery Failure

- 5-40%

- Redo vs. back on PPIs

• PEH Failure

- 25-40%

- ? anatomic vs. clinical failure

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Failed ARS & PEH – Management Challenging

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• What is failure?

• How to work-up?

• Decision about redo

• Intraoperative- Technically demanding

- What to do (e.g., take down wrap, mesh, full wrap)

Redo ARS and PEH – Success is Possible

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307 redo fundoplications in 285 patients

1,89210 fundo internal

18710 fundo external 54 fail (2.8%)

421st redo external

22st redo external

17 fail (7.1%)

4 fail (6.8%)

1 fails (17%)

1st redo fundoplication241

2nd redo fundoplication59

3rd redo fundoplication6

4th redo fundoplication4th redo fundoplication

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Failed ARS & PEH – Keys to Success

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• Know patterns of failure

• Diagnostic work-up

• Patient selection

• Intraoperative management

ARS & PEH – Patterns of Failure

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ARS & PEH – Patterns of Failure

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ARS & PEH – Patterns of Failure

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• It all starts here

• Pattern of failure determines indication for surgery

• Correlate symptoms & diagnostics to pattern of failure

• Strong correlation predicts success

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Prior Antireflux / PEH Surgery

Redo Antireflux +/- G-tube

EGDBaSw

Anatomically Normal

Obvious Anatomic Problem

Confirm GERD

pHEMSGES

No GERD

Symptom Correlatio

n

EMSGES

Entertain Other Diagnosis

Patterns of

Failure

Failed ARS & PEH – Work-up

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• Read your own contrast GI studies

• See endoscopy directly (do endoscopy yourself or go to GI unit)

• No one better that you to recognize and correlate failure patterns

Redo ARS & PEH – Patient Selection

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Not everyone with failure should have a redo

65 yo male, 6 years of good response, now with recurrent HB and hiatal hernia with wrap undone

Presentation Redo?

Easy Yes

32 yo female, never completely better after wrap, “loose wrap”, pH slightly increased

No

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Two Predictors of Outcome

Patient Selection

Operative Technique

Redo ARS & PEH – Operative Management

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• Start on left

• Enter mediastinum from left & posterior

• Open gastrohepatic well away from hiatus – “cheater plane” over caudate

• Always take down prior wrap unless its your own and immediate hiatal herniation

• Consider PEG if difficult dissection / large hernia

Redo ARS & PEH – Summary

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• Failure happens

• Become an expert diagnostician

• Correlate symptoms & diagnositics to pattern of failure – beware no correlation

• Technical execution in OR critical

• Get help

• Good outcomes are possible