Mastering Surgical Innovation · Quality of Life Results • Heartburn-Related QOL in 186 patients – Median HRQOL score 5 – Range (0- 35) • Excellent outcomes in 52% • Satisfactory

AATS Focus on Thoracic Surgery: Mastering Surgical Innovation

Las Vegas, NVOctober 27, 2017

Session II: Benign Esophageal Disease

Failed Anti-Reflux Surgery - When andHow to Re-Operate

James D. Luketich MD, FACSHenry T. Bahnson Professor and Chairman,

Department of Cardiothoracic Surgery University of Pittsburgh Medical Center

Disclosures

• No disclosures related to current talk

• Acknowledgements: Katie Nason, Arjun Pennathur, Residents and Fellows

2

General Overview

1. The approach to an unhappy patient after anti-reflux surgery2. The initial interview and diagnostic studies

1. Historical review of patient prior to any surgery2. Old films, symptoms, diagnostic studies3. Operative notes

3. Medical management1. Compliance: diet, lifestyle2. Medical co-morbidities

Diabetes, scleroderma, IPF, chronic narcotic usage, chronic constipation

3. Expectations need to be realistic4. Only the most experienced esophageal surgeons should consider

embarking on re-operative antireflux surgery5. The patient has to be prepared that a simple redo may not be possible

1. Laparoscopic redo, maybe open2. Conversion to roux y, especially with high BMI3. MIE, if anatomically unsalvageable

Causes of Failure After Original Anti-Reflux Surgery

• Poor initial indications, marginal surgery, lifestyle after surgery (work, lifting) , seminal event (vomiting episodes)

• Esophageal body • clearance problem: tight or twisted wraps, motility disorder, strictures

• Fundoplication: Valve problem• too loose, too tight• improper placement on tubularized fundus (short esophagus)• Wrap slippage onto stomach (rare) • Wrap herniation

• Reservoir problem• vagal injury• diabetic• alkaline gastric reflux

Work-up: Redo Anti-Reflux Surgery• Detailed history of the events prior to original anti-

reflux surgery– Initial dominant symptoms leading to surgery– Other coexisting medical issues: example: History of irritable

bowel syndrome, use of narcotic pain medications– Response to medications, careful history – Initial response to surgery

• Review all available data– Barium Esophagram

• Before original surgery and after, and current • upper endoscopy (review old and new)

– 24-hour pH, manometry (same, presurgery, and current)– Barrett's, stricture, PEH– Read Previous Operative Report

Patient Selection for Redo Surgery: When to consider surgery ?

• Those with intractable symptoms, that began following the initial anti-reflux operation and persisted and do not respond to maximal conservative measures

– Dysphagia not responding to dilation, and dietary measures– Persistent or recurrent heartburn not responsive to PPIs– Nausea, bloating despite aggressive dietary measures– Pain, especially if new or different from that which existed prior to original

operation• Clear anatomical problems noted on evaluation, particularly in correlation with

objective tests are helpful but not absolute prior to reop decision • Complications of reflux disease

– Stricture, progressive Barrett’s– IPF or other pulmonary symptomatology– Aspiration with worsening PFT’s, helps to have documented abnormal pH testing

but not essential if you have progressive issues • Significant new symptoms after anti-reflux surgery (example: 8-9/10) that

continue despite maximal medical treatment

Yellow to Red flags: Potential Warning Signs to Rethink a Reoperative Pathway

• Several coexisting chronic medical conditions with multiple complaints, which are not correlated with GERD - Fibromyalgia, Irritable bowel syndrome

• Symptoms present prior to original operation • Chronic opiate usage, it will be ideal to address this and get patient off

chronic pain medications if possible • Presence of severe constipation from any cause that has not been

resolved• Atypical GERD symptoms, with poor correlation with objective tests,

such as a chronic cough with a normal Demeester study• Poor esophageal motility, pseudoachalasia? will a redo wrap work?

May need esophagectomy • Morbid obesity with co-morbidities: Is Roux Y a better option?

Multiple Re-ops Will No Doubt Be Harder, Success Less Likely: A Good

reason to Consider other options • 61 patients with recurrent GERD

following anti-reflux surgery• Number of prior anti-reflux surgeries

Complications Success1 27% 85%2 66%3 75% 42%

Little AG. JTCVS 1986

Investigations• New Studies:

– Restudy patient: Should be exhaustive• Ba swallow• Manometry: LES, Esophageal function, short esophagus• 24h pH study• EGD

– Nuclear medicine gastric emptying– Partner with GI medicine, concurrence on medical

failure– Obesity counseling as indicated

• Rarely schedule surgery on the first visit!

Patterns of Failure: Many times Components of More than One

Mediastinal Migration of Wrap-Hiatal Hernia

177 (64%)

Short Esophagus 119 (43%)

Misplaced Wrap 44 (16%)Loose Wrap 12 (4%)Tight Wrap 26 (10%)Disrupted wrap 11 (4%)

Not determined 22 (8%)

Awais O, Luketich JD, .. Pennathur A. Ann Thorac Surg 2011

Mediastinal Migration of the Wrap

Transhiatal Herniation?Short EsophagusCrural Integrity?Combination of both

Wrap Placed on Tubular Cardia, A Function of Short Esophagus?

Complete Disruption Rare, Usual partial with other patterns of failure present

Complete Disruption

Technical Steps-1• Schedule as first case of the day, never start this late in

the day. Scope first yourself. • Surgeon and the patient (including family) should be

prepared for a very long day with unpredictable needs– No patient should be booked for simply “redo Nissen”, what is

your plan B operation? • If unsalvageable, you should have discussed a plan B

prior to the day of the reop

Technical Steps-2

• Move From known to unknown• Right crus towards right limb of wrap, is

vagus inside or outside wrap?• Move to left crus, similar strategy• Avoid early entry into wrap• Work parallel to esophagus, into

mediastinum, gain length before going anterior to avoid vagal injury

• Most surgeons leave vagi inside the wrap• Take down wrap completely, check fundic

mobilization, should be complete

Assessment of Fundic Mobilization and Esophageal Length

Technical Steps • After your dissection, evaluate for leaks

from stomach and esophagus, on the table EGD with insufflation under water

• Fundoplication: Complete , Partial, should have been discussed preop, but intraop findings may influence your final wrap

• Crural repair: – If crural peritoneal lining preserved, primary

repair is usually possible– Consider mesh if needed


UPMC Experience: Outcomes in 275 patients

Preoperative Symptoms: Frequently More Than One Symptom!

64%


Chart1

Heartburn

Dysphagia

Regurgitation

Atypical

53.7%

36.7

27.6%

# of patients

177

164

98

74

Sheet1

# of patients

Heartburn177

Dysphagia164

Regurgitation98

Atypical74

To resize chart data range, drag lower right corner of range.

Dysphagia Score

0

0.5

1

1.5

2

2.5

3

Dysphagia Score

Before Operation After Operation

Dysphagia score improved significantly from 2.7 to 1.4

P < 0.0001


Quality of Life Results• Heartburn-Related QOL in 186 patients

– Median HRQOL score 5– Range (0- 35)

• Excellent outcomes in 52%• Satisfactory outcomes in 33%• Poor outcome in 14%Overall excellent to satisfactory results in

85% of patients Awais O, Luketich JD, .. Pennathur A. Ann Thorac Surg 2011

Improvement in Global Quality of Life

• SF-36 Global QOL– Physical Component Score: 46 during follow-

up, no significant difference compared to pre-op values or age-matched norms

– Mental Component score: 50 during follow-up, no significant difference compared to pre-op values or age-matched norms


Awais O, Luketich JD,.. Pennathur A. Ann Thorac Surg Dec 2014

Concept of Roux-en-Y for GERD

• 70% of population is obese, 5-10% morbidly

• Eliminates the Acid access to the esophagus, must use small gastric pouch

• Diverts all Bile, pancreatic enzymes– Roux limb generally in excess of 100 cm

• Weight loss– Intra-abdominal pressures improved, co-

morbidities addressed

• Thoracic team does our own, we have done over 800 roux y’s (some are done as primary procedure for the GERD patient with morbid obesity)

• We do not see bariatric patients primarily for obesity • Why thoracic surgeons:

– Roux y for upper gastric cancers– Certain trauma situations– For a reop Nissen: hiatal hernia repair, wrap takedown, all the nuances of

a reop consideration less appreciated by a bariatric surgeon• Over a 12-year period, 105 patients with body mass index (BMI)

greater than 25 underwent RNYNEJ for failed antireflux operations. • Most were obese (median BMI 35)• Esophageal dysmotility was demonstrated in more than one-third of

patients. • Forty-eight (46%) patients had multiple antireflux operations before

RNYNEJ, and 27 patients had undergone a previous Collis gastroplasty.


Roux-en-Y Reconstruction

Changes in preoperative versus postoperative symptoms in patients after RNYNEJ


Results

• During follow-up (mean, 23.39 months), median BMI decreased from 35 to 27.6 (p < 0.0001)

• Mean dysphagia score decreased from 2.9 to 1.5 (p < 0.0001).

• The median GERD HRQOL score improved from 20 to 9 (classified as excellent).

Patient Factors in Favor of Roux-en-Y

• BMI, Obesity• Multiple prior operations • Esophageal dysmotility• Delayed gastric emptying• Medical Co-morbidities • Obese patient with IPF

Esophagectomy

• Esophagectomy as the final surgical option can be considered if redo fundoplication or Roux-en-Y is not feasible or desirable

Patient Factors in Favor of Esophagectomy

• Severe esophageal dysmotility• Multiple prior operations, vagal injuries• Strictures, Barrett's• Obstructive symptoms• HGD/Cancer• Lower BMI

Outcomes After Esophagectomy for the Treatment of Failed Prior Antireflux

SurgeryPresented at STS 2016

Omar Awais, DO, James Luketich MD, Tadeusz D Witek, MD, Valentino Bianco, DO, Ryan Levy, MD, Matthew Schuchert,MD, William Gooding, MS, Arjun Pennathur, MD

Surgical Approach

• Primary symptoms dysphagia, pain, dumping• Majority had multiple reops prior to MIE consideration• The primary surgical approach for esophagectomy

was transthoracic (35/39, 90%).• The stomach was the most common used

esophageal replacement conduit (used in 36 of 39 patients, 92%).

• Very narrow conduit, high intra-thoracic anastomosis• No perioperative, in-hospital, or 30-day mortalities

occurred.

Outcomes During Follow-up

• The median length of follow up was 31 months

• The median GERD-HRQL after esophagectomy was 9

• 90% of patients rated their outcome as “improved”

Conclusions-1• Exhaustive work-up, careful decision-making• Indications for surgery: significant symptoms unresponsive

to exhaustive attempts at medical management– Linked to reflux or simply– Not present prior to Anti-reflux surgery

• Complex operation, Steep learning curve• Contributing problem areas:

– Shortened esophagus: stricture, PEH, Barrett's– Missed diagnosis or under appreciation of motility disorders– Obesity, narcotic use, other medical co-morbidities

– Inexperienced surgeon

Conclusions-2• Laparoscopic reoperative anti-reflux surgery can

be performed safely in centers with extensive open and laparoscopic esophageal experience

• Multiple prior surgeries lower success rates for a simple reop Nissen approach – Consider Roux-en Y NEJ in the obese patient – Esophagectomy is an option in few highly selected

patients after failed anti-reflux surgery, especially multiple failures

• Best approach: Get it right the first time!

Thank You

AATS Focus on Thoracic Surgery: � Mastering Surgical Innovation� Las Vegas, NV� October 27, 2017��DisclosuresGeneral OverviewCauses of Failure After Original �Anti-Reflux SurgeryWork-up: Redo Anti-Reflux Surgery Patient Selection for Redo Surgery: When to consider surgery ? Yellow to Red flags: � Potential Warning Signs to Rethink a Reoperative Pathway �Multiple Re-ops Will No Doubt Be Harder, Success Less Likely: A Good reason to Consider other options InvestigationsPatterns of Failure: Many times Components of More than OneMediastinal Migration of the WrapWrap Placed on Tubular Cardia, A Function of Short Esophagus?Complete Disruption Rare, Usual partial with other patterns of failure present Technical Steps-1Technical Steps-2 Slide Number 16Technical Steps UPMC Experience: Outcomes in 275 patientsPreoperative Symptoms: Frequently More Than One Symptom!Dysphagia ScoreQuality of Life Results�Improvement in Global Quality of Life �Slide Number 23Concept of Roux-en-Y for GERDRoux-en-Y ReconstructionChanges in preoperative versus postoperative symptoms in patients after RNYNEJResultsPatient Factors in Favor of Roux-en-YEsophagectomyPatient Factors in Favor of Esophagectomy�Surgical ApproachOutcomes During Follow-upConclusions-1Conclusions-2Thank You

Documents

Mastering Surgical Innovation · Quality of Life Results • Heartburn-Related QOL in 186 patients – Median HRQOL score 5 – Range (0- 35) • Excellent outcomes in 52% • Satisfactory