Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1401_Библиотеки_им_академика_М_И_Перельмана.pdf
8 Redo Antireux Surgery
If an anatomic derangement is discovered on immediate postoperative imaging,
the patient should return to the operating room for repair of the recurrent hiatal
hernia or revision of the fundoplication. If this is discovered several days postoperatively, it is best theoretically to wait approximately 3months to undergo redo-ARS
to avoid the dense adhesions and inammatory response seen during this portion of
the healing process. Should the surgeon unfortunately be forced to operate during
this period, a tedious dissection should be expected, with an increased risk of intraoperative complications.
75
Late Failure
Late failure is generally dened as a patient who initially experienced good
postoperative results having return of symptoms more than 90days after surgery. Late failure is much more common than early failure. Reux symptoms
are typically due to an anatomic breakdown of the hiatal repair or disruption of
the fundoplication, while dysphagia is usually secondary to scarring or twisting
at the hiatus. The average length of time between primary and redo-ARD has
recently been shown to be approximately 42 months [15]. Morgenthal et al.
report that despite a recurrence rate of approximately 32% at 10years, most of
these patients are asymptomatic, and 93.3% of all patients state they would have
the procedure again [16, 17].
Presentation
The most common symptoms leading to reoperative antireux surgery are recurrent
reux, dysphagia, and regurgitation [7]. Return of reux and heartburn, or atypical
symptoms of reux such as chronic couch, hoarseness, or aspiration are the prevailing symptoms when there has been a wrap disruption. Improvement of symptoms
after re-initiation of antisecretory medication can be a key clinical clue during the
patient interview. Dysphagia, noncardiac chest pain, and regurgitation occur more
frequently after recurrent hiatal hernia or crural stenosis. This can be seen also in
patients with complications from prior hiatal mesh placement. Good response to
endoscopic balloon dilation can be an important clinical indicator. Postprandial
bloating, early satiety, and irregular bowel movements should raise suspicion for
iatrogenic vagal nerve injury resulting in gastroparesis.
Approximately two-thirds of failure patients report recurrent or persistent reux.
When analyzing this data, it is important to dene failure, as it is widely accepted
that subjective symptoms often do not correlate with objective testing. In fact, studies show that abnormal pH-studies are found in only 23–39% of patients reporting
postoperative reux symptoms [18]. Conversely, pathologic esophageal acid exposure after fundoplication may not always be symptomatic. Hunter etal. reported that
13% of patients had abnormal routine pH-studies 12weeks after laparoscopic fundoplication, but none of these patients reported reux symptoms [19].
76
B. Parker and K. Reavis
Dysphagia occurs is approximately one-third of patients with failed
ARS.Dysphagia is more common after a complete 360 degree fundoplication when
compared to partial fundoplication [9, 20]. Oftentimes, patients who complain primarily of dysphagia have no obvious cause on preoperative workup or intraoperative exploration. For patients with ongoing symptoms with no underlying cause
after a complete physiologic and anatomic foregut workup, consider a psychological evaluation to rule out psychosomatic disorders. For the above reasons, it is crucial to establish regularly scheduled 24-hr pH monitoring as part of all patients’
postoperative follow-up protocol, with the addition of a more extensive foregut
workup for symptomatic patients, including endoscopy, barium esophagram, and
high-resolution esophageal manometry.
Workup
The complexity of redo-ARS requires a comprehensive evaluation of the patient to
determine the exact etiology of their symptoms and to determine candidacy for
certain revisional techniques. It is of utmost importance to obtain the operative note
from the primary surgery, with attention focused on the extent of dissection, status
of the vagus nerves, possible mesh placement, and conguration of the wrap. The
rst diagnostic step in working up a symptomatic patient with prior ARS presenting
to your ofce is typically a contrast esophagram to outline the patient’s anatomy and
give some indication to the physiology of bolus transit.
Repeat esophagogastroduodenoscopy should be performed, ideally by the
operative surgeon, to identify the location of the gastroesophageal junction
(GEJ) and assess for hiatal hernia or esophagitis (Fig. 8.4). The
Fig. 8.4 Contrast
esophagram showing
recurrent hiatal hernia in a
patient with prior Nissen
fundoplication who
presented with nausea and
epigastric discomfort. Note
the presence of the
fundoplication above the
diaphragm. (Image
courtesy of Christy Dunst)
8 Redo Antireux Surgery
Fig. 8.5 Endoscopic
retroexed view of a
herniated wrap. The image
depicts an intact
fundoplication, tightly
adherent to the shaft of the
scope, which has migrated
above the diaphragm. The
crus is seen in the left
lower corner of the picture.
(Image courtesy of
Christy Dunst)
77
squamocolumnar junction (SCJ) should be characterized and biopsied. If the
patient had a previously placed mesh, it is imperative to assess for erosion,
which can be managed with endoscopic resection and expectant extrusion prior
to the redo-ARS (Fig.8.5).
A 48-hour Bravo™ pH capsule or Restech™ Dx-pH sensor can be inserted
during this same endoscopic procedure to objectively test for pathologic esophageal acid exposure and establish a baseline esophageal DeMeester or oropharyngeal RYAN Score for postoperative follow-up pH testing. Alternatively, the patient
can undergo catheter-based 24-hr pH monitoring. It is imperative to ensure the
patient is not actively taking antisecretory medications that may mask the results.
High- resolution esophageal manometry (HRM) is essential, as patients with
esophageal motility disorders such as achalasia who present with regurgitation are
unfortunately still misdiagnosed with GERD.HRM can also help guide the surgeon’s decision as to what type of fundoplication to perform. If the patient has
evidence of ineffective esophageal motility, a partial fundoplication may prevent
postoperative dysphagia. Patients who present with large paraesophageal hernias
may not be able to have manometry successfully performed, and if completed, the
results may be difcult to interpret. Figure8.6 depicts the topography of a patient
with prior fundoplication, who has manometric evidence of a recurrent hiatal hernia.
If postprandial abdominal bloating is present, a nuclear medicine gastric emptying study is helpful to assess for gastroparesis, which can occur after iatrogenic
injury of the vagus nerves during the primary procedure. If delayed gastric emptying is discovered, the patient would likely benet from a concurrent pyloroplasty or
decompressive gastrostomy tube.
78
Fig. 8.6 High resolution manometry of a patient with prior Nissen fundoplication, showing recurrent hiatal hernia. Note the presence of normal peristalsis, but two distal esophageal high-pressure
zones. (Image courtesy of Christy Dunst)
B. Parker and K. Reavis
Surgical Options andTechniques
As previously mentioned, there are several techniques available for patients with
failure of ARS.Many of these options can be approached via the abdomen or transthoracic, either open or laparoscopic, depending on surgeon preference. Robotic
assistance is also becoming part of many surgeons’ armamentarium. The most common surgical options include redo-fundoplication with the addition of a Collis gastroplasty or hiatal hernia repair as needed, conversion to Roux-en-Y (RNY)
gastrojejunostomy, or minimally invasive esophagectomy (MIE). With the advent of
newer antireux procedures, such as the transoral incisionless fundoplication (TIF)
and the magnetic sphincter augmentation (MSA) device, revisional techniques have
also been established, and will be described later.
Redo-Fundoplication
Revisional fundoplication is the preferred surgical technique at many advanced
foregut centers for patients with prior failed ARS.Redo fundoplication is known to
be technically challenging and laborious, and for this reason, has historically
required a laparotomy or thoracotomy. As today’s surgeons have gained more
expertise in advanced laparoscopy, redo-fundoplication is now primarily completed
8 Redo Antireux Surgery
79
via a laparoscopic approach, which offers superior visualization of the upper abdomen and mediastinum. The conversion rate from laparoscopy to open is approximately 1–2.5% [21, 22].
Technique
The patient isss placed supine or in lithotomy position with steep reverse
Trendelenburg. After careful access to the abdomen is gained, the pneumoperitoneum is established. Perihepatic adhesiolysis is performed and a liver retractor is
placed. An energy device is used to transect the pars accida and the gastrohepatic
ligament, using the caudate lobe of the liver as a reliable landmark to begin the dissection. Dissection is carried toward the right crus taking care not to injure the
celiac artery pedicle or inferior vena cava, as there are often wrap adhesions in this
area and distorted tissue planes can mislead the surgeon. A previously placed mesh
can also produce a challenge in the dissection of the retro-esophageal window. If the
approach from the right crus seems too difcult, moving to the left crus is recommended, using the greater curvature of the stomach as a reliable landmark to begin
dissection. The esophagus is circumferentially freed from all surrounding adhesions, with special attention toward identifying and protecting the anterior and posterior vagus nerves, if present. A Penrose drain placed around the GEJ can assist
with retraction. If a hiatal hernia is found, the recurrent hernia sac, if one has
reformed, is reduced and excised. Extensive mediastinal dissection is performed,
freeing the intrathoracic esophagus at least 5cm above the hiatus, ensuring ligation
of any penetrating arterial branches from the aorta. The previously created wrap is
taken down by cutting the gastro-gastric sutures with an ultrasonic shear or laparoscopic scissors. The epiphrenic fat pad is then excised. Adequate intra-abdominal
esophagus is then ensured to be at least 2–3cm in length without applying traction.
At this juncture, the need for an esophageal lengthening procedure via wedge fundectomy is assessed.
Crural repair is then completed with permanent suture in a sequential horizontal
mattress fashion, with the option of adding an onlay mesh for reinforcement to the
cruroplasty. If undue tension is present, a diaphragmatic relaxing incision with inlay
permanent mesh patch closure may be required. Lowering the pneumoperitoneum
during hiatal closure can also be a useful adjunct. The short gastric vessels are then
ensured to be properly ligated, and the new fundoplication is created. Intraoperative
impedance planimetry with EndoFLIP® can also be useful to act as a “smart” bougie during the formation of the fundoplication to measure the length and distensibility of the wrap (Fig. 8.7) [23]. Whether a complete or partial fundoplication is
performed should be dependent on each patient’s clinical scenario, symptoms, and
preoperative high-resolution manometry. In general, complete fundoplication is
performed for reux and hiatal hernias, while partial fundoplication is chosen for
patients with preoperative dysphagia. Many surgeons perform intraoperative upper
endoscopy to rule out underlying mucosal injury or perforation via an air insufation test, as well as to inspect the quality and conguration or the wrap. A transhiatal
closed suction drain is typically left at the end of the procedure.
80
B. Parker and K. Reavis
Fig. 8.7 The functional lumen imaging probe balloon catheter (EndoFLIP®) before (left) and
after (right) fundoplication. Sixteen impedance planimetry sensors measure a distensibility index
to help guide the creation of the wrap. An elongated hourglass appearance depicts a properly
formed fundoplication. Note the absence of overt stenosis or high pressurization. (Image courtesy
of Christy Dunst)
Hiatal Hernia Repair withMesh Reinforcement
It is the author’s practice to always use an onlay bilayered fully resorbable mesh for
complex hiatal closures (Fig.8.8). This can be secured to the crura with either laparoscopic sutures or laparoscopic tacks. If tacks are used, care is taken to avoid injury
to the IVC, aorta, or pericardium. A study of 26 patients with previous mesh cruroplasty, undergoing redo-ARS, reported a recurrent hiatal hernia rate of 70% [15]. It
should be noted that nearly half of these patients had biologic mesh placed during
the primary operation, which is known to have high recurrence rates.
8 Redo Antireux Surgery
81
ab
Fig. 8.8 (a, b) Placement of an absorbable onlay mesh, incorporated into the cruroplasty closure
with permanent suture. The nal hiatal suture is secured after Bougie is removed. (Image courtesy
of Christy Dunst)
Fig. 8.9 Collis
gastroplasty completed
with an articulating linear
cutting stapler, to obtain
>3cm intra-abdominal
neo-esophageal length.
The stapler is placed
tightly alongside a bougie
dilator to prevent a
proximal dog ear, which
can lead to the formation
of a postoperative
epiphrenic diverticulum.
(Image courtesy of
Christy Dunst)
Collis Gastroplasty fortheShort Esophagus
Axial tension is a major contributor to recurrent hiatal hernia, the leading cause of
failed primary ARS. Short esophagus has been estimated to be present in 21–43%
of patients undergoing redo-ARS [14, 24]. Due to the prevalence of the short
esophagus and the high rate of recurrent hiatal hernias, it is necessary for the
reoperative surgeon to have a low threshold to tubularize the stomach and create
a neoesophagus in order to gain adequate intra-abdominal length. One study
showed that patients with a short esophagus and prior failed ARS reported better
subjective symptoms resolution and satisfaction scores after Roux-en-Y reconstruction versus redo- fundoplication with Collis gastroplasty (Fig.8.9). It should
be noted that this study actually reported no difference in objective outcomes and
a lower complication rate in the subset of patients undergoing redo-fundoplication
and Collis gastroplasty [25].
82
B. Parker and K. Reavis
Diaphragmatic Relaxing Incision
Radial tension is also a major component of recurrent hiatal hernia and failure of
antireux operations. Redo-ARS notoriously have scarred, brotic crura that will
not easily oppose one another. If the cruroplasty seems to have undue tension, the
best way to control this is via a diaphragm-relaxing incision. Covering a tight repair
with an onlay mesh will not ofoad the radial tension on the crus, and therefore
large defects with high radial tension should not be considered an indication for
mesh placement. The right diaphragm should be the rst option for making a relaxing incision, as this is easier to perform. If full-thickness incision of the right diaphragm between the IVC and right crus does not gain adequate relief, then a
left- diaphragm relaxing incision should be made. Diaphragmatic defects are then
patched with a permanent inlay mesh. It is important to leave an adequate cuff a
diaphragm along the IVC for successful patch closure (Fig.8.10).
Roux-en-Y Gastrojejunostomy
Morbid obesity has been shown in most studies to be an independent risk factor for
the development of GERD, as well as for failure of ARS [26–28]. However, there is
some evidence to also support equivalent outcomes between obese and nonobese
patients undergoing primary ARS, raising concern for publication bias [29]. There
is clear evidence in the bariatric literature to show that GERD improves after RNY
gastric bypass [28, 30]. Knowing this, there has been an increasing trend to convert
prior failed fundoplications to a Roux-en-Y gastrojejunostomy (RNY), particularly
in patients with morbid obesity, as the procedure not only improves reux by
bypassing or eliminating gastric-acid-producing cells, but also offers additional
health benets seen with weight loss. Additionally, RNY is gaining traction as the
preferred technique for patients with prior failed ARS and concomitant gastroparesis, esophageal dysmotility, intraoperative gastroesophageal injury during redoARS, or many previous foregut procedures. In cases of extremely distorted
Fig. 8.10 Full thickness
right diaphragmatic
relaxing incision to ofoad
radial tension on the
cruroplasty. Care is taken
to avoid injury to the IVC,
which is behind the
surgeons left-handed
grasper in this image.
(Image courtesy of
Christy Dunst)
8 Redo Antireux Surgery
83
postprocedural anatomy, or in the event of gastric cardia or distal esophageal injury,
a total gastrectomy with RNY esophagojejunostomy is offered. Interestingly, Kent
et al. demonstrated improved outcomes with RNY as the primary surgery for
patients with scleroderma and severe esophageal dysmotility [31]. In general, if
patients with two or three prior failed ARS present with severe recurrent foregut
symptoms not amenable to endoscopic therapy, an RNY or total gastrectomy should
be offered [32, 33].
Converting to an RNY has shown to be effective in nearly 93% of patients, with
high subjective patient satisfaction scores [2]. There is also great objective evidence
to support this technique in the morbidly obese, with DeMeester scores demonstrated to decrease from approximately 57–12.5 after revisional RNY [3]. One concern with RNY becoming the procedure of choice is the high complication rate
published in the literature, ranging from 21% to 46% [7]. The anastomotic stricture
rate can approach 28%, and this is likely due to the relatively small pouch created
during RNY, and the resultant ischemia from the many prior foregut surgeries this
patient population undergoes. Luckily, most of these strictures can be successfully
managed with endoscopic dilation [34]. Mittal et al. concluded that despite the
higher postoperative complication rate, patients with more complex foregut pathology benet more from conversion to an RNY reconstruction rather than redofundoplication, as evidenced by higher one-year postoperative satisfaction scores
[25]. However, one must remember that with this technique comes the accepted
long-term risk of dumping syndrome, nutritional deciencies, internal hernia, marginal ulcer, afferent limb syndrome, and bacterial overgrowth, which are not typically seen after redo-fundoplication.
Technique
After gaining abdominal access and establishing pneumoperitoneum, the right
crus is identied, and dissection is carried out in a clockwise direction until the
left crus is identied. The previous fundoplication is circumferentially freed from
the hiatus and any adhesions. If the vagus nerves are still intact, these are identied and protected. If any remaining short gastric vessels are present, these are
then ligated with a bipolar device or an ultrasonic scalpel. The previous wrap is
completely deconstructed and the GEJ is identied. Alternatively, the previous
fundoplication can be left in place and the stomach can be transected just distal to
this. The short gastric vessels are ensured to be adequately transected. An endoGIA linear cutting stapler is used to create a gastric pouch, ensuring to preserve
the left gastric artery. Creating a small 5–10cm pouch is extremely important to
ensure no acid-producing parietal cells remain in direct communication with the
esophagus. There is debate whether to leave to remnant stomach in place or perform a subtotal gastrectomy. Leaving it in place offers the benet of a simpler
procedure and reserving a gastric conduit in the event an esophagectomy is
required in the future. The omentum is divided with an energy device to decrease
tension on the anastomosis. The RNY reconstruction is then created with a >50cm
biliopancreatic limb to minimize the risk of bile reux and a >100cm alimentary
limb in an ante-colic fashion. The antimesenteric gastrojejunal anastomosis and
84
B. Parker and K. Reavis
jejunojejunostomy are created with an endo-GIA stapler, and the common enterotomies are closed with intracorporeal suturing. Stapling of the common enterotomy between the jejunojejunostomy can also be used.
Minimally Invasive Esophagectomy
Minimally invasive esophagectomy (MIE) is typically considered the last resort for
patients with severe esophageal dysmotility and previously failed ARS, or in patients
who develop esophageal pathology following several previously failed ARS such as
a long esophageal stricture not amenable to dilation or pseudoachalasia with massive esophageal dilation. It is also a bail-out strategy in the event that the GEJ cannot
be reconstructed. Reoperative intervention in patients with mesh at the hiatus is
associated with a higher need for esophageal resection [15]. Managing the anatomic
and physiologic complexities in these patients can be quite challenging, and indications for up-front esophagectomy are still debated. An alternative rescue procedure,
known as the Meredino procedure, as recently been proposed for patients with many
prior failed fundoplications. It involves resection of the gastroesophageal junction
with jejunal interposition. A 2018 series of 12 patients undergoing this alternative
technique found high postoperative complication rates (67%), with 25% of patients
ultimately requiring conversion to an RNY within 12months [35]. At this time, the
Merendino procedure does not appear to be a viable surgical strategy for redo-ARS
for the majority of patients.
Technique
There are many MIE techniques, each with its own advantages and disadvantages. This procedure is technically demanding, requires a significant learning
curve, and should be performed only by experienced surgeons at high-volume
centers. MIE can be done with a combination of laparoscopic, thoracoscopic,
or robotic approaches. Each technique is safe and efficacious, and the preferred
approach depends on surgeon or institutional preference. The two most popular
approaches for benign foregut disease are the transhiatal approach and the
Ivor-Lewis technique. The transhiatal approach involves an abdominal and left
cervical incision with the anastomosis placed in the left neck. This technique
does not require single- lung ventilation and only supine positioning. The placement of the anastomosis outside of the chest has a theoretical advantage of
decreasing the morbidity of anastomotic leaks. It is a great option for benign
disease of the GEJ and patients with poor pulmonary function. The transthoracic Ivor Lewis technique involves an abdominal and right thoracic approach
with a right chest anastomosis. Patients require single-lung ventilation and
typically require both supine and left lateral positioning. Avoiding a neck incision leads to decreased recurrent laryngeal nerve injury compared to other
techniques. This approach also allows for better lymph node harvest in achalasia patients who have developed squamous cell carcinoma. Lastly, the threeincision McKeown technique requires right thoracic, abdominal, and left