Revisional Anti-Reflux Surgery - Practice Guidelines

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Definition

 

• Elective revisional surgery to correct symptoms after previous fundoplication or LINX procedures (excludes acute complications of primary procedure)​​

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Classification

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Classification of previous Anti-Reflux surgery failure requiring revisional surgery

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Type I        

In-situ fundoplication disruption

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Type II       

In-situ fundoplication slip

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Type III      

Trans-hiatal fundoplication migration

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Type IV      

Mixed fundoplication disruption and trans-hiatal fundoplication migration

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Type V       

Trans-hiatal fundoplication slip

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Type VI      

LINX failure (migration/erosion/persistent dysphagia/poor symptom control)

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Indications for surgery

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• troublesome persistent dysphagia following previous anti-reflux/LINX surgery (resistant to non-surgical therapy)

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• patients in whom the primary symptom is volume reflux/regurgitation despite previous anti-reflux/LINX surgery

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• a confirmed diagnosis of recurrent acid reflux after previous anti-reflux/LINX surgery and adequate symptom control with medical therapy but do not wish to continue with long term therapy

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• patient with breakthrough symptoms despite maximum medical therapy for recurrent reflux after previous anti-reflux/LINX surgery

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• a confirmed diagnosis of acid reflux in patients following previous anti-reflux surgery/LINX and symptoms that respond to medical therapy but who are intolerant of medication side effects

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• atypical symptoms such as aspiration, cough or hoarse voice and confirmed evidence of GORD in patients treated previously with anti-reflux/LINX surgery (these patients as a group have less successful outcomes than patients with typical symptoms)

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• LINX explant for erosion/migration

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• LINX explant for psychological reasons​​

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Investigations

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• Previous operative notes

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• OGD endoscopy

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• GI Physiology- ambulatory pH/high resolution manometry

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• Barium swallow

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Management 

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• Revisional surgery has more complex management and should be concentrated to a few surgeons within a large unit or a single centre within a region

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• Pass all patients through a hiatal MDT prior to surgery

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• Enter data into a registry to audit outcomes

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Key performance Indicators 

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• Mortality < 0.1%