Anatomic fundoplication failure after laparoscopic antireflux surgery.

Area of Science:

• Gastroenterology
• Surgical Innovation
• Laparoscopic Surgery

Background:

• Laparoscopic antireflux surgery (LARS) is increasingly used for gastroesophageal reflux disease.
• Postoperative symptoms can arise from physiological issues or anatomic fundoplication failure.
• Limited data exist on causes and management of anatomic fundoplication failures.

Purpose of the Study:

• To determine the incidence of anatomic fundoplication failure after LARS.
• To identify presentation, precipitating factors, and management strategies for these failures.

Main Methods:

• A 6-year study of 290 LARS procedures by a single surgeon.
• Comparison of two surgical techniques: selective vs. routine diaphragmatic crura closure and fundic mobilization.
• Postoperative evaluation including clinical assessment and diagnostic testing for symptomatic patients.

Main Results:

• Anatomic fundoplication failure occurred in 7% of patients, predominantly during the initial learning curve (Group 1).
• Common presentations included intrathoracic wrap migration or disruption, often heralded by chest pain.
• Failure correlated with learning curve phase, early postoperative vomiting, diaphragmatic stressors, and large hiatal hernias.

Conclusions:

• Anatomic fundoplication failure is a significant complication of LARS, particularly in early cases.
• Technical factors such as inadequate crural closure and insufficient fundic mobilization are implicated.
• Meticulous surgical technique, including full esophageal mobilization and complete diaphragmatic crura closure, is crucial for minimizing failure.