Surgery for Complex Disorders of the Upper Digestive Tract

Abstract

In this thesis, the complexity of surgical treatment for failed antireflux procedures and large hiatal hernias (type II-IV) is described. The studies in the first part have addressed the results of antireflux surgery after previous endoscopic or surgical procedures performed for refractory gastro-oesophageal reflux disease. It was previously shown that primary antireflux surgery fails in 10-15% of patients in the long run and, although conservative treatment is adequate in the majority of patients, surgical reintervention is necessary in 3-6%. Symptomatic and objective outcomes of surgical reintervention for failed antireflux surgery are, with a success rate of 70-80%, substantially lower than those of primary surgery, as was shown in a cohort study and a systematic review of the literature in this thesis. Herein, risk factors for renewed failure appeared to be difficult to identify. Additionally, redo antireflux surgery is accompanied with relative high morbidity and even mortality. An anatomical explanation for failure of the previous surgical antireflux procedure, including wrap disruption, telescoping (ie, cephalad migration of the gastro-oesophageal junction through the wrap), intrathoracic wrap migration, or para-oesophageal hiatal herniation (ie, intrathoracic migration of a part of the stomach with the wrap in its normal subdiaphragmatic position), was found during redo surgery in 90% of patients. Compared to primary surgical procedures, antireflux surgery after a previous endoluminal EsophyX fundoplication, recently introduced to offer an alternative for life-long use of antisecretory drugs and to avoid prolonged recuperation of antireflux surgery, may be accompanied with a higher risk of intraoperative gastric injury and postoperative troublesome dysphagia. However, a previous endoluminal EsophyX fundoplication should, at this stage, not be considered an additional risk factor in antireflux surgery, as it does not influence the outcome with regard to reflux control. The second part of this thesis has focused on the surgical treatment of large hiatal hernias. Because of the documented advantages over the open repair, including less complications, less postoperative pain, and shorter hospital stay, the laparoscopic repair is the preferred approach in the surgical treatment of large hiatal hernias. It was shown in this thesis that the long-term symptomatic outcome of laparoscopic large hiatal hernia repair is satisfactory in 90% of patients. A substantial number of patients, however, has anatomical recurrence (30%). A difference in symptomatic outcome between patients with and without anatomical recurrence was not found. Although an antireflux fundoplication does not prevent anatomical recurrence, the addition of a fundoplication is strongly recommended during large hiatal hernia repair, as reflux oesophagitis or pathological acid exposure is induced in a substantial number of patients if a fundoplication is omitted. Herein, the addition of a fundoplication does not negatively influence the symptomatic outcome in terms of new-onset daily complaints of dysphagia. Additionally, it was shown in this thesis that, in comparison with an antireflux fundoplication primarily performed for refractory gastro-oesophageal reflux disease, the extensive surgical dissection during laparoscopic large hiatal hernia repair, required to restore the anatomy, is not accompanied with more frequent or more severe dyspeptic symptoms.