Master Techniques in Surgery: Esophageal Surgery free download
Abstract: With laparoscopic primary fundoplication now a well-established treatment for gastroesophageal reflux disease (GERD), there is an increasing number of patients that are being referred for complex re-operative intervention for failed primary fundoplication. The majority of patients presenting with failed primary fundoplication can be managed non-operatively, a subset of patients will benefit from re-operative surgery. Re-operative anti-reflux surgery can usually be performed using minimally invasive techniques with good results. The key principle of re-operative surgery for failed fundoplication is establishing and restoration of normal anatomy. It is also essential to perform complete mediastinal esophageal mobilization to recognize a short esophagus, and to preserve crural integrity. The surgical options for an anti-reflux procedure include redo-fundoplication, and Roux-en-Y near esophagojejunostomy (RNYNEJ). In some instances, esophagectomy may be indicated.
In conclusion the surgical management for failed fundoplication is highly complex, and requires extensive pre-operative work-up. Despite this, re-operative intervention for failed fundoplication can usually be accomplished with minimally invasive techniques. Surgical options include redo-fundoplication, RNYNEJ, gastropexy, or esophagectomy. Optimal surgical option is dependent on pre-operative work-up, intra-operative findings, and patient characteristics. Good to excellent outcomes can be achieved for re-operative anti-reflux surgery when performed by experienced esophageal surgeons at high volume centers.