FAILURE AFTER FUNDOPLICATION: RE-FUNDOPLICATION? IS THERE A ROOM FOR GASTRECTOMY? IN WHICH CLINICAL SCENARIES?

ABSTRACT Background: Re-fundoplication is the most often procedure performed after failed fundoplication, but re-failure is even higher. Aim: The objectives are: a) to discuss the results of fundoplication and re-fundoplication in these cases, and b) to analyze in which clinical situation there is a room for gastrectomy after failed fundoplication. Method: This experience includes 104 patients submitted to re-fundoplication after failure of the initial operation, 50 cases of long segment Barrett´s esophagus and 60 patients with morbid obesity, comparing the postoperative outcome in terms of clinical, endoscopic, manometric and 24h pH monitoring results. Results: In patients with failure after initial fundoplication, redo-fundoplication shows the worst clinical results (symptoms, endoscopic esophagitis, manometry and 24 h pH monitoring). In patients with long segment Barrett´s esophagus, better results were observed after fundoplication plus Roux-en-Y distal gastrectomy and in obese patients similar results regarding symptoms, endoscopic esophagitis and 24h pH monitoring were observed after both fundoplication plus distal gastrectomy or laparoscopic resectional gastric bypass, while regarding manometry, normal LES pressure was observed only after fundoplication plus distal gastrectomy. Conclusion: Distal gastrectomy is recommended for patients with failure after initial fundoplication, patients with long segment Barrett´s esophagus and obese patients with gastroesophageal reflux disease and Barrett´s esophagus. Despite its higher morbidity, this procedure represents an important addition to the surgical armamentarium.

摘要
背景：胃底折叠术（fundoplication）失败后，再次胃底折叠术（re-fundoplication）是临床最常实施的补救术式，但此类患者的再失败率更高。
研究目的：① 探讨此类患者初次胃底折叠术与再次胃底折叠术的临床疗效；② 分析胃底折叠术失败后，何种临床情境下可考虑实施胃切除术。
研究方法：本研究队列纳入104例初次手术失败后接受再次胃底折叠术的患者、50例长节段巴雷特食管（Barrett´s esophagus）患者及60例病态肥胖患者，从临床、内镜、食管测压及24小时pH监测等维度对比各组的术后结局。
研究结果：初次胃底折叠术失败的患者中，再次胃底折叠术的临床结局最差，相关指标包括症状评分、内镜下食管炎表现、食管测压结果及24小时pH监测结果。长节段巴雷特食管患者接受胃底折叠术联合Roux-en-Y远端胃切除术后，临床疗效更佳；肥胖患者亚组中，行胃底折叠术联合远端胃切除术与腹腔镜胃旁路切除术的症状改善情况、内镜下食管炎表现及24小时pH监测结果无显著差异，但仅在胃底折叠术联合远端胃切除术的患者中，食管下括约肌压力恢复至正常水平。
研究结论：推荐对初次胃底折叠术失败患者、长节段巴雷特食管患者，以及合并胃食管反流病（gastroesophageal reflux disease）与巴雷特食管的肥胖患者实施远端胃切除术。尽管该术式的术后并发症发生率更高，但它仍是外科诊疗手段库中重要的补充方案。