Gianmattia del Genio and Jean-Marie Collard
In the last three decades, surgical procedures for gastroesophageal reflux disease showed significant improvements in outcomes mainly because of standardization of the indications, widespread use of accepted fundoplication techniques, and improved perioperative management. Despite the good results of the currently adopted operations,1 acute complications of anti-reflux procedures occur and may be life-threatening. Large series with careful long-term follow-up are available and demonstrate recognizable patterns of failure.2-6 Complications are different in type and frequency in relation to both techniques (e.g., partial vs total fundoplication) and approach (e.g., thoracotomy vs laparotomy). Recently, the evolution toward the use of the laparoscopic approach7-9 changed the frequency of these untoward events. Some of the complications traditionally associated with open surgery decreased in incidence (e.g., inci-sional hernia, splenic injury), whereas other specific complications (e.g., intraabdominal hemorrhage, herniation of the wrap into the chest, perforation of the esophagus or stomach, pneumothorax, or pneumomediastinum) occur more frequently after laparoscopic surgery.10,11 Because of the high number of anti-reflux procedures performed each year and the lack of any worldwide registry, the exact incidence of acute complications is difficult to estimate. Follow-up studies report a large statistical variation influenced by the relatively small numbers of operations performed in each individual institution. Retrospective surveys of laparo-
scopic anti-reflux procedures demonstrate an operative mortality of 0.5%12 and a morbidity ranging from 4 to 7.3%.13,14 A nationwide analysis comprehensive of all the serious complications was conducted in Finland between 1987 and 1996, showing a prevalence of 0.8% of life-threatening complications including 0.1% of fatal events.15 Even though a substantial number of surgical failures do not lead to remedial surgery, another method to estimate the incidence of postoperative complications is to consider the reoperation rate. According to Carlson and Frantzides,16 the overall reoperation rate reported in the literature for all the primary anti-reflux laparoscopic procedures published between 1993 and 2000 was 2.8%.
In laparoscopic anti-reflux surgery there is a direct correlation between the surgeon's experience and the complication rate17 with the highest complication rate occurring during the first five cases and declining to a more acceptable level beyond the twentieth procedure.18 The important role of tutorship is demonstrated by the lower complication rate and shorter operative time during the learning curve of late starters than in the initial experience of pioneers.18
This chapter addresses the main acute complications of anti-reflux surgery irrespective of the approach (laparotomy vs laparoscopy vs thoracotomy) and their timing of occurrence (intraoperative vs postoperative). It provides the reader with relevant information, guidelines, and insights that have evolved from study of the
MANAGING FAILED ANTI-REFLUX THERAPY
surgical literature and from the senior author's personal experience.
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.