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I'm gong to do re-dos and roux-en-Ys or esophagectomy in a reoperative setting. So to kind of
highlight some of the data that's out there in the literature again and see how these complicated
patients that we are seeing with multiple re-dos, how to manage them best.
So as you know the pathophysiology of a paraesophageal hernia, there's a weakening of the
phrenoesophageal ligament, it could be circumferential which leaves a tight hiatal hernia, focal, a
paraesophageal component, and then we believe that there are contributing factors to this whether it's
obesity or age. So these are acquired defects that happen over time. Eventually a small hiatal
hernia can lead to this giant paraesophageal hernia which the majority of the patients we manage
with an anterior reflux operation.
Now are these paraesophageal hernias really asymptomatic? Probably not. The issue is that a lot of
these patients are living with these large hernias and they've learned to essentially control the
symptoms whether eat smaller meals over time, so they probably have minimal symptoms. They are
not asymptomatic And the question becomes is you know when do you intervene? And these are
various amount of symptoms that we all have seen in our practices how these can present. And let's
not forget that at sometimes some of these patients present with anemia only, as the only findings. I
mean I've seen many patients in my practice where they work the patient for anemia and they've
done everything except looking at a scan showing a huge hernia in the chest. So certainly that's one
of the manifestations. then you have mechanical problems with the giant paraesophageals like
compression, arrhythmias, pneumonia, dyspnea, etc.
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Now this is the paper that we all go back to, at least in our practice, and compare the Toronto
experience of 30 year by Griff Pearson, looking at the repair of these big hernias to a transthoracic
approach. And as you can see that at that time they were using Collis pretty liberally on these
patients. The follow-up was excellent, as you can see from the slide, with the detailed questionnaire,
barium esophagrams, manometry, pH testing, etc. So it's really a benchmark paper in terms of the
giant paraesophageal repair. And again this is over a 30 year experience of a single surgeon. The
results excellent, 94% of patients have excellent results, recurrence rate again only 2 patients, 2%,
very low. Reoperative rate again 2 patients, so again this is a very good experience and with a very
good follow-up with excellent outcomes and radiographic recurrence are extremely low.
On the other side you see as the era of laparoscopy starting in 1991 with the first lap Nissen that
patients were starting - surgeons were doing giant paraesophageal hernia laparoscopically. As you
can see here this is a very honest depiction of an outcome of laparoscopic paraesophageal repair
where the recurrence is 42% at a very fairly intermediate follow-up. Open experience in their hands
is 15%. So a lot of these patients are going to need reintervention whether it's going to be a
reoperative Nissen repair with a bad curl closure, gastropexy which we will hear later, or a roux-enY or esophagectomy.
Now then in our institution we've done over as you can see this publication (inaudible) will talk
about perhaps over 600 patients over a 10 year period. So compared to Pearson's 30 year experience
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over nearly 100 patients today, a much larger experience in the area of laparoscopy. This was also a
prospective quality in surgical outcomes database, basically looking at our experience over 10 years
at a single institution. And most of the surgeries were performed by one or two or three surgeons in
that area.
Again they were completed laparoscopically nearly all of them, liberal use of Collis gastroplasty,
probably more so in the first third or first 3 years, and then it kind of decreased in the last 6 years.
Mesh cruraplasty again was performed early in the experience but nowadays we don't perform it
routinely. But the important thing here is that in this experience you can see the outcomes are pretty
good as opposed to one the by Shemy that was published with recurrence with 40%. This is
somewhere closer to the Griff Pearson data where radiograph recurrence is about 4%. Less than 4%.
Symptomatic improvement excellent, 3.2% patients underwent a reoperation for subsequent followup, so compared to very high rate of recurrence for 40% in some experience, with Pearson's open
experience 2% is close to less than 4%.
And then we look at this metaanalysis that was performed inclusion criteria for this was more than
25 patients and at least 6 months follow-up. And here you can see that 13 studies were eligible and
the overall recurrence rate of 10.2%. So what is the actual recurrence rate? It depends on institution,
it depends on the surgeon, various factors but somewhere along the line of 5 to 20% where you are
going to have the giant paras recur which is going to need a reoperation in their lifetime. Now what
are the surgical options for this?
Well one, most of these patients will undergo a re-do
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fundoplication with or without a lengthening procedure. A lot of them nowadays will go under a
gastropexy which Dr. Luketich will talk about. It's an excellent option if you do it the right way.
And then there is a subset of patients which will not undergo any of those two but will require a
roux-en-Y or an esophagectomy. So disease severity as you can see is increasing from one operation
to the other, right. We know from other experiences that the number of re-dos has increased, the
complication rate dramatically increased from 1, 2 to 3. We know the success rate drops
dramatically from the first re-do to second to third re-do. So putting that into the equation you can
see how these patients are becoming more complicated in terms of their surgical management.
Now the level of evidence that we have for recurrent hiatal hernia repair, giant paraesophageal
hernia repair is at best single institution, case series reports, retrospective with a prospective database
and can we really extrapolate the outcomes from a failed fundoplication data to giant
paraesophageal?
Well all paraesophageal hernia repairs have some type of reflux procedure right, so perhaps we can
extrapolate the data and use it for the giant para recurrence.
Options for re-do anti-reflux surgery as I mentioned, why do we hear the roux-en-Y as opposed to
esophagectomy? This is one - this is the reason why. Number 1, as I mentioned, the diminishing
success of multiple reoperations or multiple fundoplications as I, in an earlier slide, the morbidity in
the best event with esophagectomy as you know the mortality is 1 to 5%, it is high, anywhere from
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10 to 40%. Roux-en-Y in the setting of current obesity epidemic becomes an attractive option in that
subset of patients, so you are addressing not only the obesity, you are addressing the reflux also.
But what is roux-en-Y reconstruction? This is essentially an operation that the gastric bypass has
been performed for morbid obesity however is tailored for a reflux patient for two reasons. One, the
gastric pouch is a lot smaller, it's devoid of any fundus, it's mostly made of gastric cardia. Number
2, the roux-en is not as long as 150 cm, it's a lot smaller, so you don't have the malabsorptive effects
or the weight loss effects. And number 3, sometimes we add a decompressive gastrostomy tube to
allow for the stomach to heal and perhaps the leak occurs if you can feed the patient antrally.
The concept is very simple, you eliminate the acid by making a very small pouch which is devoid of
fundus, mostly of cardia, you divert the bile by making a roux-en, at least 60 cm based on their BMI,
and then you have the added benefits of weight loss from the roux-en-Y. So you can see how rouxen-Y is a very attractive option for reflux control. Now why we have adopted a smaller pouch here?
Well in this paper by Sapala in 2000 you can see the micro pouch has a very low rate of reflux
peptic esophagitis. And the leak rate is less than 1%. So over 1000 patients with making a pouch in
the gastric cardia you can see how the outcomes are very good in terms of reflux.
So this experience here from UPMC essentially the - is a very large experience, the largest of its kind
comparing - looking at actually a failed antireflux surgery and a conversion to roux-en-Y near
esophagojejunostomy. The reason we had near because we are making the anastomosis really of the
gastric cardia almost at the level of the esophagus.
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We looked at our outcomes, end points essentially were perioperative outcomes, failure of roux-enY, and assessment overall of patient quality of life, (inaudible) GERD or dysphagia scores. This was
again a retrospective review over 10 year experience, over 105 patients. Primary indications were
one prior antireflux operation and intractability to medical therapy. Patients as you can see were
very complicated. Number 1, very complex - I'm sorry, number one, almost 50% of the patients had
2 prior antireflux operations, 2 or more. 26% are prior Collis gastroplasty. Dysmotility was seen in
nearly half of the patients. 80% of the patients were obese, that means BMI more than 30. So very
complicated patients and quite a bit of them have gastric emptying issues and also esophageal
dysmotility.
The technique of the procedure is pretty - as you can see most of them were performed minimally
invasive but do not hesitate to open these patients and do a good operation. So about 50% were
completed laparoscopically, another 50% were completed open. And the key here is you have to
take down the wrap completely, you have to restore normal anatomy just by - just for any re-dos.
You have to see where the esophagus ends, the cardia and fundus, do a leak test intraoperatively,
complete your roux-en-Y.
This is a little video, you can see the poor placement, anatomy has been reestablished. The partition
is at the level of the cardia above the fundus. The gastrotomy is made, either a transoral EEA can be
used here, or we can put an EEA through the esophagus directly. The transoral is better because it's
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easier to put in 25 EEA through the mouth and you don't have to manipulate the pouch too much.
Normally we'll put a purse string there, you established - reconstruct your anatomy by doing a
jejunostomy, the jejunostomy with a linear stapler and you do a proximal anastomosis with the EEA,
25 EEA.
Then you reset the blind (inaudible), close the hiatus with a single stitch or 2 stitch posteriorly,
sometimes a buttress that with omentum, wrap it around the anastomosis, put a drain behind it, it's a
reoperation so the leak is a little bit higher, so if it would leak it would catch it very nicely. So
essentially it was an edited video, a 4 hour operation in a matter of 1 minute. So essentially the
points I'm going to make there is that you try to make - you establish normal anatomy, you make the
pouch small, at the level of the cardia and you can use some pearls to reduce the leak rate by putting
mentum around it and leave a drain there.
So in our experience the length of stay was 6 days, mortality was zero. Complications, major
morbidity was 24%, and our leak rate was about 10%. So morbidity is significant however the
outcomes in terms of reflux are also great. As you can see here, improvement of symptoms, all
symptoms, heartburn, regurgitation, dysphagia, pulmonary symptoms were significantly improved
after convergence to roux-en-Y.
Dysphagia score measured by a tool that we use here pre and post-op dysphagia significantly
improved from 2.9 to 1.5 post operatively. BMI dropped from the morbidly obese range to the
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overweight range and at 27.6 and the GERD-HRQOL score also were in the excellent range in terms
of reflux control. Added benefits of improvement in comorbidities such as hypertension, sleep
apnea, diabetes and cholesterol among other things that are improved dramatically or resolved n
most of the patients. In terms of a failure rate of roux-en-Y at a mean follow-up of 23 months, 5
patients required re-operation out of 105 for a recurrent hiatal hernia.
The good thing about the roux-en-Y conversion is that the data that (inaudible) has been
reproducible no matter what institution you look at, what series you look at back from 2005 to 2013
the same results have been seen. So indicating the reproducibility and the efficacy of roux-en-Y as
an antireflux operation
So as you can see here despite in our patients despite having a higher
morbidity and a higher preoperative motility issues, Collis 26%, 2 or more prior operations 46% that
the GERD control based o the GERD-HRQOL score, a drop in BMI, morbid comorbidities, 0
mortality and morbidity 24% were comparable to other experiences that have been published. So
this essentially favors doing it in very select patients who are morbidly obese, who have recurrent
symptoms and maybe a recurrent hernia that roux-en-Y might be an attractive option in those
patients.
Some have even suggested hat in comparison to fundoplication versus roux-en-Y in a reoperative
setting that roux-en-Y may be better in some patients. For example if they have a higher number of
risk factors for poor outcome roux-en-Y might be a better option on those patients as opposed to
doing a re-do fundoplication.
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Here you can see that in those patients in head-on comparison between roux-en-Y and a re-do Nissen
that patients with esophageal motility disorders were less likely to have poor outcomes after roux-enY. In addition the postop dysphagia was better with roux-en-Y compared to patients who had a redo Nissen and a Collis. Also the - in patients who had more than 4 risk factors the ones who had
roux-en-Y they had a better result and better outcome as opposed to doing a re-do fundoplication.
There were patient factors that we can look at that may tilt the pendulum towards doing a roux-en-Y
as opposed to say an esophagectomy, BMI, the patient is morbidly obese. Primary GERD
symptoms, heartburn, multiple prior reoperations, although you can say esophagectomy would be as
an option, in those patients as you know esophagectomy can cause reflux postoperatively. So
therefore roux-en-Y may be a better option in those patients. Esophageal dysmotility and based on
what we've seen that if you have severe dysmotility perhaps esophagectomy is a better option, but if
you have mild to moderate dysmotility maybe roux-en-Y may be a better option for those patients.
Delayed gastric emptying and again specifically for roux-en-Y, medical comorbidities and the most
important ones are brittle diabetes and sleep apnea. So you may want to steer those patients who
have a recurrent hiatal hernia towards the roux-en-Y.
So roux-en-Y near esophagojejunostomy after failed hiatal hernia can be performed safely with
good results in experienced centers. And it's more applicable in obese patients and those who have
esophageal dysmotility and it's an important surgical option for patients for a patient with a failed
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antireflux surgery. When considering roux-en-Y for patients with hiatal hernia and intractable
GERD the approach still has to be individualized. The level of evidence we have is basically single
institution case series, so we still have to individualize the approach to those patients.
When do you want to consider esophagectomy as opposed to roux-en-Y? Well in the literature again
the data is not that robust, but there is a couple of experiences out there, one from Michigan and one
from Mayo. And this is from the Michigan experience published in 2010 and they looked at - they
wanted to value with impact of prior antireflux operation on the outcomes after esophagectomy for
recurrent GERD or hiatal hernia. So they basically you know compared patients who had a prior
reflux procedure or hiatal hernia when doing an esophagectomy compared to patients who did not
have a prior reflux procedure and doing an esophagectomy. So it was a retrospective review of
patients when doing esophagectomy for recurrent hernia essentially looking at outcome analysis.
And some of the selection they had in this 20, 30 year period on the patients who were steered
towards esophagectomy with a recurrent hiatal hernia were number 1, who had Barrett's esophagus.
Now you may say well you now nowadays, in this day and age in somebody who had Barrett's
esophagus and hernia you have options, pexy, Nissen, roux-en-Y and can ablate the Barrett's so
maybe esophagectomy may not be an option nowadays. But clearly in their selection this was one of
the indicators for them to perform an esophagectomy. Similar high grade dysplasia can be managed
many ways nowadays that was one of their selection criteria. Stricture, which I think still stands
because if you have a severe stricture doing a roux-en-Y or a pexy or a Nissen is not going to solve
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the problem. The organ, the disease, severity, the esophagus has to be removed. Multiple prior
operations, similarly you can consider roux-en-Y on those patients too. They have to look at other
patient factors not only multiple operations. Obstructive symptoms, I think ties in with stricture.
Severe dysmotility, stricture, obstructive symptoms, perhaps esophagectomy may be a better option
in those patients.
So they basically identified 258 patients and they compared 104 patients who had a prior hernia
repair and Nissen to 154 patients who had no prior surgery and esophagectomy. And then in their
analysis basically you can see that a transhiatal was accomplished which it's not really an important
point as far as I'm concerned, it's to do the esophagectomy whichever way you want to do it, Ivor
Lewis or transhiatal. So a transhiatal was accomplished in less patients with a prior reflux operation.
More importantly I think it's important to see here their experience at a gastric conduit was used in
fewer patients. So you have to prepare those patients for possible Collis, I'm sorry for a colon
imposition. More blood loss was seen in patients who had esophagectomy after a prior Nissen, or
hiatal hernia repair. And more importantly, you can see here that more likely require reoperation
about 14% of patients.
So as opposed to in our experience with roux-en-Y the need for
reintervention surgically was about 5% need for intervention after esophagectomy and in organ
space about 14%. So it's a bit high.
Fewer to good results were seen in patients who had a prior reflux procedure, 50 versus 69%. And
also the one who had a prior reflux operation had significantly more moderate to severe dysphagia,
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so indicating the complexity of the operation after a prior reflux procedure esophagectomy has a
high morbidity, perhaps poor outcomes compared to doing an esophagectomy without a prior reflux
operation.
So in their conclusion esophagectomy after a hiatal hernia repair can be accomplished without a
thoracotomy, which I think is a moot point. You do the operation which you have been trained to do
whether it's Ivor Lewis or transhiatal with satisfactory quality of life. The patient to be evaluated for
alternative conduit which I think is a more important point, that in their hands they recognized that
the stomach may not be suitable as a conduit so the patient had to be counseled upfront for a
(inaudible) position.
This is the experience from Mayo, this will give you a little different flavor of esophageal resection
after a reflux procedure than the (inaudible) experience. So their aim was to review the patients
undergoing esophagectomy after fundoplication, similarly to the Michigan experience. They
identified 80 patients over a 20 year period who underwent an esophagectomy after at least one prior
operation. And they compared match controls in their experience. So like (inaudible) experience yo
can see here that the indications for esophagectomy after a prior reflux procedure were similar,
stricture, some of them had cancer, some had dysplasia. However as you can see that disease of the
esophagus with a stricture is far significant, so therefore in those situations if you compare to rouxen-Y esophagectomy may be a better option.
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Their operative mortality was higher, it was 3.7%, their morbidity was significantly higher to 62.5%
and unlike Morringer's experience which was at 14% the need for reoperation, they had a need for
reoperating 20%. So the morbidity and mortality is much higher in their experience. Leak rate 21%,
if you compare the leak rate to our experience was about 10% from the Michigan experience about
10%, leak rate in this experience was 21% in performing esophagectomy after a prior reflux
operation. So data on mass controls, post-op complications, anastomotic leak, need for reoperation
were all significantly higher in patients who had a prior reflux operation.
So these are very
complicated patients, that's the message you should get out of this. This should be done with
surgeons with vast experience in high volume centers of excellence. And then in uni-varied and
multi-varied analysis prior history of reflux surgery was associated with increased post-op
complications and leak. And here you can see the conclusion of the paper, again complications,
anastomotic leak, reoperative rates are higher in patient who underwent esophagectomy after prior
antireflux operation compared to mass controls.
This was an experience again from Michigan a few years later in 2013, again respectively identified
over a 30 year period in patients who underwent esophagectomy for benign disease. And the most
common indications for benign disease in this paper was acolasia failure and reflux or hiatal hernia.
And they noted that a patient progressed to esophagectomy more rapidly if they had an acquired
disorder like reflux, they were older, age more than 18, prior fundoplication and number of prior
operations. So again the complexity of the patients as you can see here based on their multiple prior
operations and motility issues and strictures. However unlike the experience from Mayo you can see
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here the mortality is a lot lower, 1%. The leak rate is half that on the Mayo experience. Reoperation
rate is half that from the Mayo experience so you know indicates that esophagectomy after a reflux
operation is morbid and has a high complication rate and a high mortality.
So what patient factors unlike roux-en-Y would favor esophagectomy more? Well for roux-en-Y
perhaps mild to moderate dysmotility may be better suited. Esophagectomy I believe severe
dysmotility the organ is diseased and perhaps in that setting esophagectomy is a better option.
Multiple prior operations, it depends. It depends on many factors, BMI, co-morbidities, does he
have diabetes, sleep apnea, whether you are able to preserve the vagal integrity, you know many
reasons, many factors. But these discussions would happen with the patient upfront in an office
setting. It should not be an intraoperative decision, this should be discussed with the patient upfront.
Stricture I believe is a very strong indication towards esophagectomy in a reoperative setting or a
failed hiatal hernia. Obstructive symptoms similarly go hand in hand with stricture formation. And
high grade dysplasia, cancer also in that setting you may want to proceed with esophagectomy,
perhaps not Barrett's esophagus but perhaps high grade or cancer, or early tumor. BMI again if the
patient may not be in this day and age may be normal weight and multiple re-dos of patient with a
prior giant paraesophageal or hiatal hernia repair and normal BMI, well doing a roux-en-Y on those
patients may not be ideal, maybe they'd be served best with a narrow gastric tube and then
esophagectomy. So esophagectomy after prior failed hiatal hernia surgery is challenging and carries
a very high morbidity indicated by two large experiences. It should be performed by experienced
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surgeons at high volume centers, and you have to have a careful selection of patients due to a high
morbidity that I've shown here on the slides.
When considering esophagectomy versus roux-en-Y for recurrent hiatal hernia you have to look at
many factors. Age, you don't want to deal with roux-en-Y with somebody 80 years old, right, or
esophagectomy. Those patients will be better served with a gastropexy or a partial Nissen. BMI it's
clearly if the BMI is more than 30 you should favor a roux-en-Y on those patients and especially if
you have comorbidities like diabetes, sleep apnea. Esophageal function, important to do motility
tests on these patients preoperatively to identify how severe the motility is so you can tell them
listen, you will be better served with esophagectomy or roux-en-Y. Dysplasia and cancer, as you can
see nowadays with ablative therapy these are kind of - have to be you can go either way, certainly
not with cancer. Clinical symptoms, I feel that reflux patients are better served with roux-en-Y in a
reoperative setting and I feel a patient with dysphasia and stricture are probably better served with
esophagectomy after a failed paraesophageal or hiatal hernia.
Patient preference, some patients you know there is a stigmata for roux-en-Y, stigmata of
esophagectomy, they don't want it. You have to do your best to guide them based on your
preoperative testing, but sometimes the patient (inaudible) with data to help them out. A patient who
had a BMI of 30 and probably should have had a roux-en-Y done but we did an esophagectomy
because the patient did not want a roux-en-Y and she had very severe symptoms. So that has to be
also considered in your algorithm and your - when you are deciding what to do.
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Assessment should be performed by experienced surgeons at high volume centers and a lot of times
these patients come back to your office a few times, they have to be educated about both surgical
options and also the morbidity, the mortality and the outcomes. Level of evidence says we have now
is at best case series reviews from single institutions. There is no prospective studies, most of them
are retrospective reviews and so therefore what we can recommend now is an individualized
approach to these patients who have very complicated problems.