Reoperative Antireflux Surgery for Failed
Fundoplication: An Analysis of Outcomes in 275
Patients
Omar Awais, DO, James D. Luketich, MD, Matthew J. Schuchert, MD,
Christopher R. Morse, MD, Jonathan Wilson, BS, William E. Gooding, MS,
Rodney J. Landreneau, MD, and Arjun Pennathur, MD
Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, and The University of Pittsburgh Cancer Institute
Biostatistics Facility, Pittsburgh, Pennsylvania
Background. With an increase in the performance of
laparoscopic antireflux procedures, more patients with a
failed primary antireflux operation are being referred to
thoracic surgeons for complex redo procedures. The ob-
jective of this study was to evaluate our results of redo
antireflux surgery.
Methods. We conducted a retrospective review of pa-
tients who underwent redo surgery for failed fundopli-
cation. The primary endpoint was failure of the redo
operation; other endpoints included gastroesophageal
reflux disease-health-related quality of life (HRQOL)
after redo fundoplication.
Results. A total of 275 patients (median age, 52 years;
range, 17 to 88 years; men 82, women 193) underwent
redo antireflux surgery. The most common pattern of
failure of the initial operation was transmediastinal mi-
gration-recurrent hernia in 177 patients (64%). Redo sur-
gery included Nissen fundoplication in 200 (73%), Collis
gastroplasty in 119 (43%), and partial fundoplication in
A n increasing number of minimally invasive antire-
flux procedures are being performed and patients
are increasingly being referred to thoracic surgeons for
complex redo operations for failed repairs [1, 2]. The
failure rates for primary fundoplication range from 2% to
30% [3– 8]. Although many patients with mild recurrent
symptoms can be managed nonoperatively, 3% to 6% of
primary antireflux procedures will require a reoperative
intervention [9].
In a recent systematic review, approximately one-third
of redo antireflux surgical procedures were performed
laparoscopically [10]. The success rates for either open or
laparoscopic reoperative surgery, however, are not equal
to those of primary antireflux operations. Little and
colleagues [3], in an important study, reported that only
84% of patients undergoing open reoperative antireflux
Accepted for publication Feb 24, 2011.
Presented at the Forty-sixth Annual Meeting of The Society of Thoracic
Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010.
Address correspondence to Dr Luketich, Department of Cardiothoracic
Surgery, University of Pittsburgh, 200 Lothrop St, Ste C-800, Pittsburgh,
PA 15213; e-mail: luketichjd@upmc.edu.
© 2011 by The Society of Thoracic Surgeons
Published by Elsevier Inc
GENERAL THORACIC
41 (15%). There was no perioperative mortality. At a
median follow-up of 39.6 months, 31 patients (11.2%) had
a failure of the redo surgery, requiring reoperation. The
two-year estimated probability of freedom from failure
was 93% (95% confidence interval 89% to 96%). The
HRQOL scores, available for 186 patients, were excellent
to satisfactory in 85.5%, and poor in 14.5%.
Conclusions. Redo antireflux surgery can be performed
safely in experienced centers with outcomes that are
similar to published open results. Complete takedown
and reestablishment of the normal anatomy, recognition
of a short esophagus, and proper placement of the wrap
are essential components of the procedure. Thoracic
surgeons with significant laparoscopic and open esoph-
ageal surgical experience can perform minimally inva-
sive, complex redo esophageal antireflux procedures
safely with good results.
(Ann Thorac Surg 2011;92:1083–90)
© 2011 by The Society of Thoracic Surgeons
surgery achieved a satisfactory result and the percentage
of patients with satisfactory results declined to 42% in
patients who had undergone three or more operations.
Redo antireflux surgery is a complex operation, and a
thorough evaluation is essential before treatment. One of
our goals in patients with benign esophageal disease is
esophageal preservation. There are several options for
reconstructive antireflux surgery including redo fundo-
plication and Roux-en-Y near esophagojejunostomy,
which is applicable particularly in obese patients. After
multiple failed redo operations, esophagectomy may be
the only viable option. The main objective of this study
was to evaluate our experience with reoperative surgery,
without resection, for failed primary fundoplication. Our
primary aim was to evaluate the outcomes after reopera-
tive antireflux surgery.
Material and Methods
We retrospectively reviewed our experience with pa-
tients who underwent reoperative surgery (excluding
esophageal resection) at the University of Pittsburgh
0003-4975/$36.00
doi:10.1016/j.athoracsur.2011.02.088
 1084 AWAIS ET AL
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION
Medical Center from 1996 to 2008 after failed fundopli-
cation. This study includes a follow-up of our original
series [11] and was approved by our Institutional Review
Board. As this was a retrospective study, individual
patient consent was waived.
Preoperative Evaluation and Investigations
Patients who were candidates for reoperative antireflux
surgery underwent a comprehensive evaluation, with a
complete history and physical examination; investiga-
tions performed included barium esophagram, esopha-
gogastroduodenoscopy, esophageal manometry, pH test-
GENERAL THORACIC
ing, and gastric emptying studies. In addition, the details
of the previous operative procedure were reviewed prior
to the reoperation. Data on preoperative variables, in-
cluding gender, age, symptoms, type of surgery, and the
pattern of failure, were collected. Dysphagia scores were
assessed preoperatively and postoperatively (Table 1).
Surgical Technique
Our technique for a minimally invasive approach for
redo operations has been detailed previously [11]. In
brief, an arterial line is used to assess potentially labile
hemodynamics due to a potential pneumothorax that can
occur during the mediastinal dissection. An on-table
endoscopy is performed to assess anatomic abnormali-
ties and also to rule out esophageal mucosal lesions, such
as high grade dysplasia or cancer, which may change our
operative approach. This is followed by safe port place-
ment, with the initial port placed by an open technique.
Lysis of adhesions is performed systematically and me-
ticulous dissection is commenced towards the hiatus. The
short gastric vessels are divided, if not done during the
prior operation. It is important to preserve the perito-
neum covering the crura and preserve the integrity of the
crura. Complete right and left crural mobilization are
essential to hiatal mobilization and eventual primary
closure. The utilization of a mesh can be limited with
complete crural mobilization and preservation of the
integrity of the crura. Hiatal dissection is started by
staying on the crura, as this will limit intraoperative
perforations and vagal injuries. Finally, the wrap is com-
pletely taken down and the normal anatomy is defined
prior to reconstruction. Removal of the gastroesophageal
fat pad, if not done in the prior operation, allows for
accurate recognition of the gastroesophageal junction;
this is important for proper placement of the wrap and to
assess the presence of a short esophagus. The esophagus
is completely mobilized, including mediastinal mobiliza-
tion. If 3 cm of tension-free intraabdominal esophagus is
not achieved, an esophageal lengthening procedure is
Table 1. Dysphagia Score Scale
1 ⫽ no dysphagia
2 ⫽ unable to swallow hard solids
3 ⫽ unable to swallow soft solids
4 ⫽ unable to swallow liquids
5 ⫽ unable to swallow saliva
Ann Thorac Surg
2011;92:1083–90
Fig 1. Construction of the neoesophagus with an endo GIA (gastro-
intestinal anastomosing) stapler. (Reprinted from Pierre AF, et al,
Ann Thorac Surg 2002;74:1909 –16 [12], with permission from
Elsevier.)
added. A Collis gastroplasty is performed by making a
transgastric window with an end-to-end anastomosis
stapler [12] (Fig 1), and more recently as a wedge gastro-
plasty with a linear stapler [9]. A short, floppy Nissen
fundoplication is constructed over a bougie while the
crura are approximated primarily. A distal esophageal
myotomy may be considered for patients whose motility
studies suggest pseudoachalasia [13]. Finally, our tech-
nique of Roux-en-Y near esophagojejunostomy, as de-
scribed previously, can be considered in patients who are
obese [14].
Patients were monitored during visits to the thoracic
surgery clinic. The current follow-up schedule in the
clinic is two weeks after discharge, every three months
for two years, every six months for two additional years,
and then annually.
Quality of Life
We assessed quality of life by administering the Gastro-
esophageal Reflux Disease-Health-Related Quality of
Life (GERD-HRQOL) questionnaire [15] and the Short
Form 36-Item Health Survey (SF-36). The SF-36 is an
instrument that measures the general health-related
quality of life and is a well-established instrument used
in a variety of conditions. The SF-36 estimates both the
physical and mental components of the quality of life
[16], which are aggregated to two summary measures:
physical component score (PCS) and mental component
score (MCS). The SF-36 transformed summary PCS and
MCS scores were derived using the Quality Metric soft-
ware program (Quality Metric, Lincoln, RI). The GERD-
HRQOL questionnaire is a disease-specific instrument
consisting of nine questions (recently expanded to 10)
related to heartburn, regurgitation, dysphagia, diet, and
bloating, with responses from 0 to 5.The best possible
score (no symptoms) is 0 and the worst possible score
Ann Thorac Surg AWAIS ET AL 1085
2011;92:1083–90 REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION

(most severe symptoms) is 50 [15]. We classified HRQOL Table 3. Patterns of Failure

scores as excellent (0 –9), satisfactory (10 –15), or poor
Reason for Failure No. (%)
(16 –50) [11].
Mediastinal migration of wrap, 177 (64.4%)
Statistical Design and Analysis hiatal hernia
The primary outcome variable was failure of the redo Short esophagus 119 (43.3%)
procedure requiring reoperation and secondary end- Misplaced wrap 45 (16.4%)
points included the quality of life measures after redo Loose wrap 12 (4.4%)
surgery. Kaplan-Meier plots were constructed using Tight wrap 26 (9.5%)
Greenwood confidence limits for estimation of failure- Disrupted wrap 11 (4%)
free survival. The time-to-failure analysis was performed Not determined 22 (8%)
from the time of the first reoperation performed by our

GENERAL THORACIC
group. In addition, analysis of individual covariates pre-
dictive of failure was performed with the Wald test.
Comparison of dysphagia scores was done by the signed time from the prior operation to the redo operation was
rank test. 36 months.

Patterns of Failure of the Prior Operation and

Results
Patient Characteristics
There were 275 patients who underwent surgery for
failed primary fundoplication. Their median age was 52
years (range, 17 to 88 years). The majority of patients had
one prior antireflux surgery; 31 patients (11.3%) had more
than one prior antireflux procedure. Patient characteris-
tics are summarized in Table 2. The most common
presenting symptoms were heartburn in 63.6% (175 of
275), and dysphagia in 49.5% (136 of 275). Other present-
ing symptoms included regurgitation in 32% (88 of 275),
and atypical symptoms in 29.5% (81 of 275) of patients.
A preoperative upper endoscopy (273 of 275; 99.3%)
and contrast swallow evaluation (266 of 275; 96.7%) were
performed in nearly all patients. Upper endoscopy was
abnormal in 82% of patients. Manometry with or without
pH testing was obtained in 75% of patients (206 of 275).
Manometry was abnormal in 55% of patients (151 of 275).
These tests were not performed when a clear anatomic
defect was noted on barium contrast swallow or upper
endoscopic examination. Gastric emptying studies were
obtained more selectively (146 of 275; 53.1%). The median
Reoperative Surgery
Transmediastinal migration of the wrap or a recurrent
hiatal hernia (177 of 275; 64.4%) was the most common
cause of failure of the prior antireflux operation. Esoph-
ageal shortening was noted in 119 patients (119 of 275;
43.3%) and a defect in the crural repair was identified in
12 patients (4.4%) (Table 3).
The most common procedure during reoperation was a
Nissen fundoplication with or without a Collis gastro-
plasty (Table 2). The redo procedure was accomplished in
a minimally invasive fashion in 93% of patients (256 of
275; 93%). There were eight conversions to open surgery
due to extensive adhesions or a recognized intraopera-
tive perforation. Nine operations were started in an open
fashion. Mesh was utilized in 22 patients (8%; 22 of 275)
as a component of the repair. Major complications in-
cluded postoperative leaks, which occurred in 9 patients
(3.3%), bleeding in 2 (⬍1%), atrial fibrillation in 6 (2.2%),
pulmonary embolism in 2 (⬍1%), and Clostridium difficile
colitis in 2 patients (⬍1%). Reexploration was required in
4 patients (1.4%) for complications related to leak or
bleeding. There was no perioperative mortality. The
length of stay ranged from 1 to 75 days with a median
length of stay of 3 days.

Table 2. Patient Characteristics Failure of the Redo Operation

Characteristic No. (%) During follow-up of up to 14.5 years (median follow-up
3.3 years [39.6 months]; interquartile range 1 to 6 years),
Total patients: 275 31 patients (11.3%) had failure of the redo operation
Gender male 82; female 193 requiring surgical intervention. A redo fundoplication
Median age 52 years (range, 17–88 years) was performed in 7 patients, redo fundoplication with
Single redo surgery 244 Collis gastroplasty in 7 patients, a Roux-en-Y esophago-
Multiple redo surgeries 31 jejunostomy in 12 patients, and pyloroplasty in 1 patient.
Type of operation: An esophagectomy was required in 4 patients.
Nissen fundoplication 200 (72.7%) The estimated probability of freedom from failure was
Partial fundoplication 41 (14.9%) 95% at one year (95% confidence interval [CI] 92% to
Collis gastroplasty 119 (43.3%) 97%), 93% at two years (95% CI 89% to 96%), and 84% at
Roux-en-Y 34 (12.4%) five years (95% CI 77% to 88%) (Fig 2). Covariates were
Myotomy 5 (1.8%) analyzed to evaluate association with failure (Table 4).
Additional procedures: Age and partial fundoplication were significantly associ-
Pyloroplasty 9 (3.3%)
ated with failure of the redo operation. There was a trend
for multiple redo operations to be associated with failure.
 1086 AWAIS ET AL Ann Thorac Surg
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION 2011;92:1083–90

cation have increased due to the dramatic increase in

antireflux surgery in the 1990s [2]. The surgical options
that allow esophageal preservation for recurrent reflux
disease after failed fundoplication include performance
of another fundoplication and the construction of a
Roux-en-Y near esophagojejunostomy. In this series, we
have presented our results of reoperative surgery in 275
patients with a failed antireflux operation and found that
laparoscopic redo antireflux surgery can be performed
safely with outcomes that are similar to published open
results. Recurrence requiring reoperation occurred in
11.3% of patients at a median follow-up of 3.3 years. The
GENERAL THORACIC

estimated probability of freedom from failure was 93% at

Fig 2. Kaplan-Meier plot of the probability of failure-free survival.
Bars are 95% confidence intervals for probability of failure.
Improvement in Symptoms and Quality of Life
Paired dysphagia scores were obtained for 135 patients.
There was a significant decrease in dysphagia after the
redo procedure. The dysphagia score decreased signifi-
cantly from 2.7 to 1.4 after redo surgery (signed rank test
p ⬍ 0.0001) (Fig 3).
Routine clinical follow-up was complete in all patients.
Detailed follow-up with quality of life questionnaires was
available in 186 patients (68%; 186 of 275). During follow-
up, the median GERD-HRQOL postoperatively was 5
(range, 0 to 35). The GERD-HRQOL was excellent in
52.2% (97 of 186) of patients, satisfactory in 33.3% (62 of
186), and poor in 14.5% (27 of 186) of patients. The general
quality of life was also evaluated with the SF-36 instru-
ment in a subset of patients. The median PCS was 46.35
and the mean PCS ⫾ SEM (standard error of the mean)
was 44.38 ⫾ 0.91 (normal ⫽ 50). The median MCS was
50.83 and the mean MCS ⫾ SEM was 47.61 ⫾ 0.93
(normal ⫽ 50).
Comment
Reoperative antireflux surgery presents a challenging
problem for surgeons, and referrals for failed fundopli-
two years, and most patients experienced resolution of
dysphagia and a good quality of life after redo antireflux
surgery.
The classical approach to reoperative antireflux sur-
gery is transthoracic [3, 17, 18]. The potential advantages
of a transthoracic approach are its applicability in pa-
tients with multiple prior abdominal operations, “hos-
tile” abdomen, and when a Belsey fundoplication is
chosen by the surgeon. A transabdominal approach fa-
cilitates other intraabdominal procedures (for example,
pyloroplasty or Roux-en Y esophagojejunostomy). In a
recent systematic review of patients who underwent
reoperative surgery after a failed antireflux operation, a
transabdominal approach was used in approximately
66% of patients and a transthoracic approach in approx-
imately 25% [10]. Reports of minimally invasive laparo-
scopic reoperative surgery for failed antireflux proce-
dures are becoming more common [7–11, 19] and our
primary approach for redo antireflux procedures is a
laparoscopic approach.
Clinical Presentation and Evaluation
The primary symptoms prompting reoperation reported
in the literature are recurrent reflux and dysphagia,
similar to the primary symptoms seen in this series [10].
Dysphagia after primary antireflux surgery can be mul-
tifactorial and includes both anatomic problems with the
repair (tight wrap, long wrap, twisted fundoplication,
recurrent hernia) and esophageal dysfunction [13]. In

Table 4. Analysis of Covariates Associated With Failure

Factor Subgroup Hazard Ratio 95% CI p Value

Gender Male Ref

Female 1.75 0.72–4.3 0.212
Age — 0.97 0.95–1.0 0.028
Type of Complete fundoplication (Nissen) Ref
procedure Partial 2.77 1.21–6.36 0.016
fundoplication(Belsey/Dor/Toupet)
Redo 1 Ref
number 2 or 3 2.35 0.96–5.73 0.061
Time to — 0.995 0.99–1.0 0.240
redo
surgery

CI ⫽ confidence interval.
Ann Thorac Surg
2011;92:1083–90 REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION
Fig 3. Frequency histograms of dysphagia scores (A) before (PRE)
and (B) after (POST) reoperative antireflux surgery. Lower scores
indicate improved dysphagia. Postoperative scores were significantly
lower (improved) (signed rank p ⬍ 0.0001).
addition, persistent reflux can cause damage that leads to
functional and anatomic impairment of the esophagus.
This, coupled with prior procedures with injury to the
gastroesophageal junction and possible compromise of
the integrity of the vagi, adds to the complexities of a
redo antireflux operation.
Reoperative antireflux surgery is a complex operation
and patients should be comprehensively evaluated prior
to consideration for surgery. In particular, a barium
esophagogram and esophagogastroscopy are very useful
and provide a good delineation of the anatomic abnor-
malities, such as a misplaced wrap or tight wrap, and can
rule out esophageal neoplasia, which would require a
different approach. These investigations were utilized in
nearly all the patients in our series. Esophageal function
tests (manometry, pH testing) also provide useful infor-
mation; for example, a patient with recurrent pathologic
reflux who has abnormal peristalsis and contractility with
dysphagia may require a partial fundoplication. How-
ever, these tests are not absolutely necessary when there
is a clear anatomic defect noted on barium contrast
swallow or upper endoscopic examination, explaining
the patients’ symptoms. In patients with a suspected
vagal injury, a gastric emptying study should be
obtained.
Causes of Failure of the Primary Operation
The most common pattern of failure observed in this
series was a transmediastinal migration of wrap, essen-
tially a recurrent hiatal hernia. These findings are con-
sistent with other large reoperative laparoscopic experi-
ences [8, 10]. In a systematic review of more than 4,000
patients, transdiaphragmatic migration of the fundopli-
cation and disruption of the wrap were the most common
reasons for failure [10]. Factors potentially playing a role
in recurrent hiatal hernia are an unrecognized short
esophagus, creating longitudinal tension on the fundo-
plication, and the mode of initial diaphragmatic closure.
In our series, a short esophagus was present in approx-
AWAIS ET AL 1087
imately 40% of patients. It is critical to recognize a short
esophagus. If we are unable to achieve 2.5 to 3 cm of
tension-free intraabdominal esophagus after complete
mobilization in the mediastinum, we add a Collis gastro-
plasty to the repair. Some authors have suggested the
routine addition of a Collis gastroplasty after two failures
[7]. Others have not routinely added a Collis gastroplasty
in the management of large hiatal hernias [20]. Maziak
and colleagues [21] reported that they performed a Collis
gastroplasty for short esophagus in 91 of 94 patients with
giant paraesophageal hernia with a very low rate of
recurrent hernia. Similarly, Deschamps and colleagues
GENERAL THORACIC
[18] reported 62.7% utilization of Collis gastroplasty in
their series of reoperative antireflux surgery. In this
series of reoperative surgeries for failed fundoplication,
we used Collis lengthening with extensive esophageal
mobilization in 43% of patients.
Secure crural closure is another important technical
factor in reducing the risk of transdiaphragmatic herni-
ation with a recurrent hernia. It is important to preserve
the peritoneal lining covering the crura and preserve the
integrity of the crura. In our series we were able to close
the crura primarily in most patients and mesh was used
sparingly. Another approach that has also been de-
scribed is the routine use of pledgeted sutures to repair
the crura in combination with a Collis gastroplasty [22].
Failure of the Redo Operation
During a median follow-up of 39.6 months, 11% of the
patients in this study had failure of the redo procedure
requiring a reoperation. This is similar to other studies;
Deschamps and colleagues [18] reported that 10.8% of
patients required reoperation at a median follow-up of 31
months. Stirling and Orringer [17] reported that 12 of 73
patients required another reoperation at a mean fol-
low-up of 28 months.
The causes for failure of the redo antireflux operation
have been evaluated in few studies [3, 18]. Gender and
time from prior operation were not significantly associ-
ated with failure of the redo operation in our study and
partial fundoplication was significantly associated with
failure of the redo operation. However, a partial fundo-
plication was primarily performed in patients with
esophageal dysmotility; therefore, the baseline esopha-
geal function may, at least in part, be a factor in the
ultimate outcome. Further work is required to fully
address confounding variables, such as esophageal dys-
function, and the association of the partial wrap with
failure of the redo operation. We also observed a trend of
failure of the reoperation with an increasing number of
prior redo antireflux operations, a finding similar to that
of Little and colleagues [3]. In contrast, Deschamps and
colleagues [18] did not find that the number of prior redo
operations was a significant factor in failure. These au-
thors reported that primary obstructive symptoms of
dysphagia requiring early dilations may be a marker of
long-term failure of a redo operation.
The procedure of choice after one or more failed
fundoplications depends on many factors and the deci-
sion should be individualized. We attempt to tailor our
 1088 AWAIS ET AL
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION
approach to the specific patient, based on preoperative
testing, clinical symptoms, and intraoperative findings.
For example, a patient who has an obvious recurrence
due to the failure to recognize a short esophagus may
benefit from another attempted repair with the addition
of a Collis gastroplasty.
Finally, comorbid conditions should be taken into
consideration before redo antireflux surgery. Obesity is
associated with gastroesophageal reflux [23]. Obese pa-
tients who present with recalcitrant symptoms after an-
tireflux surgery can be considered for a Roux-en-Y near
esophagojejunostomy [14]. In patients with severe loss of
GENERAL THORACIC
esophageal function, esophagectomy may offer a better
and more definitive option when the gastroesophageal
antireflux mechanism cannot be restored [9, 14, 17, 24,
25]. Some patients have severe, complicated reflux dis-
ease (for example, a long esophageal stricture resistant to
dilation) and these patients are perhaps best served with
an esophagectomy.
Quality of Life
One of the difficulties in follow-up of patients is the
systematic assessment and standardized reporting of
postoperative symptomatic improvement. We utilized a
standardized disease-specific instrument, the GERD-
HRQOL questionnaire, to assess symptomatic improve-
ment. More than 85% of patients had excellent or satis-
factory results after reoperative surgery for a failed prior
antireflux operation. These results are comparable with
other series of reoperative surgery and with a recent
systematic review demonstrating successful symptom
resolution in 81% of patients [10].
Strengths and Limitations
This series is one of the largest experiences of redo
surgery with esophageal preservation after failed fun-
doplication. A unique feature of this experience is that
the majority of procedures were performed in a mini-
mally invasive fashion by thoracic surgeons. Limita-
tions include those common to retrospective studies,
such as selection bias of treatment and limitations in
data collection in a retrospective study. In addition,
longer follow up is required for greater maturity of
time-to-event data to allow for a more complete eval-
uation of failure of the redo operation. In addition,
further work is required to delineate the risk factors for
failure of the redo operation.
Summary and Conclusions
Redo surgery after failed fundoplication is a complex
operation, and a comprehensive evaluation should be
completed prior to performing the procedure. Redo
antireflux surgery can be performed safely in experi-
enced centers and as expected the outcomes after redo
antireflux surgery are not as good as first time proce-
dures. The operative approach depends on the under-
lying cause of failure. The reoperative procedure en-
tails complete takedown of the previous repair,
defining the gastroesophageal junction after dissection
of the gastroesophageal fat pad, reestablishment of
Ann Thorac Surg
2011;92:1083–90
normal anatomy, maintaining vagal nerve and crural
integrity, recognition of a short esophagus and the
addition of an esophageal lengthening procedure if
needed, and the proper construction of the fundopli-
cation [9, 25]. Thoracic surgeons with significant lapa-
roscopic and open esophageal surgical experience can
perform minimally invasive complex redo esophageal
antireflux procedures safely, with excellent-to-
satisfactory results possible in more than 80% of pa-
tients using minimally invasive techniques at an expe-
rienced center.
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DISCUSSION
DR DANIEL J. BOFFA (New Haven, CT): That was a very nice
talk, Omar.
How many of the patients were done at Pittsburgh primarily,
and are there any tricks that you do during your first operation
that make redos easier? And how many of the original antireflux
procedures were done open as the first approach?
DR AWAIS: Thank you Dan for your comments. In our ongoing
analysis, approximately one-third of patients underwent their
initial operation elsewhere.
In regards to initial operative approach, about 10% of patients
had a prior open operation; majority of the patients had lapa-
roscopy as their initial approach.
Although all redo antireflux operations are challenging, there
are some tricks we use to potentially make them easier. Our goal
is always to do it right the first time so that we do not have to
reoperate. It all starts with the initial and accurate assessment of
the patient’s symptoms and their correlation with objective tests.
We believe long-term success of the original operation depends
on proper diagnosis and indication for the procedure, and
during the operation, dissection of the hernia sac with reduction
of the hernia, adequate esophageal and crural mobilization with
preservation of crural lining, recognition of short esophagus, use
of a Collis lengthening when indicated, secure crural closure,
and proper construction of a fundoplication. In our initial
operation we are extremely careful in identifying and preserving
both the anterior vagus and the posterior vagus nerves. We
reflect both nerves off the esophagus in order to place our
fundoplication within both nerves. The success of the initial
operation and the reoperation depends on all these factors and
consistently following these steps during our original surgery
allows us to avoid a reoperation.
DR THOMAS FABIAN (Albany, NY): Omar, congratulations on
a nice presentation.
What percentage, and I may have missed it, were second-time
redos and third-time redos? And if you have that information,
did you compare patient satisfaction between those groups, and
how did it modify your technical approach to repairing them?
DR AWAIS: Thank you, Tom. In our series, 31 patients under-
went two prior operations and very few patients had three or
more. Our approach to all redos regardless of number of prior
operations is the same, that is comprehensive evaluation, and
when we reoperate, would be to reestablish normal anatomy,
preserve both vagi, recognize a short esophagus, and reconstruct
a new fundoplication.
AWAIS ET AL 1089
22. Whitson BA, Hoang CD, Boettcher AK, Dahlberg PS, An-
drade RS, Maddaus MA. Wedge gastroplasty and reinforced
crural repair: important components of laparoscopic giant or
recurrent hiatal hernia repair. J Thorac Cardiovasc Surg
2006;132:1196 –202.
23. Fisher BL, Pennathur A, Mutnick JL, Little AG. Obesity
correlates with gastroesophageal reflux. Dig Dis Sci 1999;44:
2290 – 4.
24. Gadenstätter M, Hagen JA, DeMeester TR, et al. Esophagec-
tomy for unsuccessful antireflux operations. J Thorac Car-
diovasc Surg 1998;115:296 –301.
25. Pennathur A, Awais O, Luketich JD. Minimally invasive redo
antireflux surgery: Lessons learnt. Ann Thorac Surg 2010;89:
S2174 –9.
GENERAL THORACIC
We did not perform any subset analysis in comparing patient
satisfaction between those groups.
DR MARK B. ORRINGER (Ann Arbor, MI): I compliment you
for a well presented paper. Your statement that reoperative
antireflux surgery is advanced esophageal surgery cannot be
overemphasized. And results such as those you have reported
require experience and a large volume of these patients.
Despite the unquestioned experience of your group, I am
concerned about your results. As a Belsey disciple, I recall a
number of us having to “twist Belsey’s arm” to let us report the
results of the Belsey Mark IV operation, which he did not want
to do until he had ten years of follow-up. The abstract of your
paper indicates that you have 23 months of mean follow-up in
these patients. You already report a nearly 10% incidence of
need to reoperate, and that is extremely worrisome and por-
tends an unacceptable failure rate. Can you comment upon your
relatively high reoperative rate?
Further, you use mesh in 24% of your patients. In all the years
that I have performed antireflux-hiatal hernia operations, I have
never used mesh at the hiatus. Placing a semi-rigid material
against an organ that is constantly moving up and down with
diaphragmatic excursions leads to esophagogastric erosion,
which we are now called upon regularly to treat. Such a
complication is a disaster for the patient and generally leads to
an esophagectomy. I personally believe that there is nothing like
being able to do these operations open, palpate and grasp the
tendinous hiatus, and place reliable hiatal sutures that obviate
the need for mesh. Have you experienced such problems with
mesh erosion in your patients?
Finally, I question the value of manometric data in these
“redo” patients. With a giant paraesophageal hernia and an
accordioned, shortened esophagus, the barium swallow and
manometry may show dysmotility. But this does not justify a
myotomy or partial fundoplication. An esophageal lengthening
Collis gastroplasty and Nissen fundoplication straighten the
esophagus, and the preoperative dysmotility seen on manome-
try has little clinical significances.
Similarly, after several antireflux operations and a partially
obstructed esophagogastric junction, manometry may show dys-
motility, but the type of fundoplication performed should not be
influenced by this. Do you really alter your redo operation based
upon preoperative manometric findings?
I’d also like to hear your thoughts on the limit of the number
of hiatal hernia-antireflux operations a patient can have before
you say that another fundoplication is destined to failure and a
different approach is needed. How many redo laparoscopic
 1090 AWAIS ET AL
REDO ANTIREFLUX SURGERY FOR FAILED PRIMARY FUNDOPLICATION
repairs are you willing to do? What dictates your decision to do
something more than just a redo fundoplication?
I very much enjoyed your paper.
DR AWAIS: Thank you, Dr Orringer, for your comments. We
acknowledge your significant contributions in this field. We
almost never use mesh during our initial operation and in this
series we report mesh utilization in less than 10% of our patients
in a reoperative setting. I concur that mesh placement at the
hiatus should be avoided if at all possible and we only reserve its
utilization in situations in which the crural integrity is destroyed.
I agree with you entirely that these are very complicated
patients who should be managed at high volume centers for best
GENERAL THORACIC
outcomes.
We agree that these outcomes can be better evaluated with
longer follow-up. However, our mean follow-up of 23 months
compares well to some of the other, few, large reported series,
and some series suggest that most recurrence occur within the
first two years. With ongoing follow-up, we have now extended
our median duration of follow-up beyond 36 months. We
continue to monitor and follow-up our patients.
And the answer to how many operations you need to do as an
endpoint for a potential esophagectomy, I think that depends on
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many factors. One, it depends on the patient’s preoperative
symptoms, such as dysphagia, and some of the objective tests we
use in our evaluation as well as number of redos.
Our goal, always the first time out, is to try to avoid a
reoperative fundoplication but, as you can see, the results are
not as good, based on many series, as you perform second, third,
or fourth redo. We see a wide spectrum of patients starting with
a young patient with obvious anatomic problem, good motility,
and normal weight. This patient would obviously be served best
by a redo fundoplication. In contrast, on the other side of the
spectrum, we may see a patient with multiple redos, severe
dysmotility, dysphagia, and poor emptying. In such a patient
esophagectomy may be the best option. In reality, most patients
present somewhere in between these two extremes and for these
we do not have all the answers. They must be studied exten-
sively and approached individually. We must tailor the opera-
tion based on their symptoms, based on their preoperative
evaluation, and also perhaps BMI [body mass index].
Finally, I would stress during the initial visit all three options,
esophagectomy, fundoplication, and Roux-en-Y are discussed in
detail with the patient, because sometimes you never know what
you will find in the OR.
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