Background: Little is known regarding the predictors of favorable outcomes following re-do Anti-reflux surgery (Re-ARS). The aims of this study were: (1) to analyze the efficacy of Re-ARS in resolving dysphagia; and (2) to identify risk factors for persistent or new-onset dysphagia after Re-ARS.
Methods: After IRB-approval, a prospectively maintained database was retrospectively reviewed to identify patients with >1 year of follow-up after Re-ARS. Dysphagia severity was graded 0-3 before and after Re-ARS based on responses to a standardized questionnaire. Patients reporting symptoms of grade 2 or 3 were considered to have significant dysphagia. Satisfaction with Re-ARS outcome was graded using a 10 point analog scale.
Results: Between December, 2003, and July, 2008, 106 patients underwent Re-ARS by a single surgeon (SKM). Significant pre-operative dysphagia was reported by 54 (51%) patients and impaired esophageal motility was noted in 31 (29.2%). Remedial surgery included redo-fundoplication (n=86, 81.2%), Collis gastroplasty with redo-fundoplication (n=16, 15.1%), take down of the fundoplication (n=3, 2.8%), and hiatal closure after lysis of dense adhesions (n=1, 0.9%). At least one year follow-up (mean 21.8 months) was available for 92 (87%) patients. In patients with significant pre-operative dysphagia (n=46) the mean symptom score declined from 2.35 to 0.78 (p<0.0001). Of these, 13 patients reported persistent dysphagia and another 4 patients reported new-onset dysphagia. No patients reported grade 3 dysphagia following Re-ARS. One patient required further remedial surgery for persistent dysphagia: others have been managed with dilations. Univariate analysis showed that esophageal dysmotility, Collis gastroplasty and pre-operative dysphagia were significantly associated with postoperative dysphagia. Multivariate logistic regression analysis identified Collis gastroplasty (p=0.03, adjusted OR=5.74) and pre-operative dysphagia (p=0.01, adjusted OR=6.80) as risk factors for significant post-operative dysphagia. The overall satisfaction score was 8.3 and 91% of patients would recommend the procedure to a friend, but there were significantly lower satisfaction scores among certain subsets. These included patients with esophageal dysmotility (7.1, p=0.04), patients who required Collis gastroplasty (7.0, p=0.09), and patients with esophageal dysmotility who required Collis gastroplasty (5.0, p<0.01).
Conclusion: Although dysphagia is a common symptom among patients requiring Re-ARS, intervention provides significant benefit. Patients with preoperative dysphagia – especially those requiring Collis gastroplasty – are at increased risk for persistent dysphagia and decreased satisfaction following Re-ARS.