Anatomical failure following laparoscopic antireflux surgery (LARS): does it really matter?

Failure rates of laparoscopic antireflux surgery (LARS) vary from 2-30%. A degree of anatomical failure is common, and the most common failure is intrathoracic wrap herniation. We have assessed anatomical integrity of the crural repair and wrap using marking Liga clips placed at the time of surgery and compared this with symptomatic outcome.

A prospective study was undertaken on 50 patients who underwent LARS in a single centre over a 3-year period. Each had an X-ray on the first postoperative day and a barium swallow at 6 months at which the distance was measured between the marking Liga clips. An increase in interclip distance of > 25-49% was deemed 'mild separation', and an increase of > 50% 'moderate separation'. Patients completed a standardised symptom questionnaire at 6 months.

At 6 months' postoperatively, 22% had mild separation of the crural repair with a mean Visick score of 1.18, and 54% had moderate separation with a mean Visick score of 1.26. Mild separation of the wrap occurred in 28% with a mean Visick score of 1.21 and 22% moderate separation with a mean Visick score of 1.18. Three percent had mild separation of both the crural repair and wrap with a mean Visick score of 1.0, and 16% moderate separation with a mean Visick score of 1.13. Of patients, 14% had evidence of some degree of failure on barium swallow but only one of these was significant intrathoracic migration of the wrap which was symptomatic and required re-do surgery.

The prevalence of some form of anatomical failure, as determined by an increase in the interclip distance, is high at 6 months' postoperatively following LARS. However, this does not seem to correlate with a subjective recurrence of symptoms.