Reflux-Rezidiv … und andere Probleme nach Fundoplikatio: Indikation zur Re-Operation

Zusammenfassung

Hintergrund: Eine frühzeitige funktionsdiagnostische Abklärung und ein adäquates problemorientiertes Management sind die wesentlichen Maßnahmen bei Auftreten funktioneller Probleme und Komplikationen nach Antirefluxchirurgie bei gastroösophagealer Refluxkrankheit.
Anamnese, Diagnostik und therapeutisches Management: Grundlegende Voraussetzung für eine sichere Aufarbeitung ist eine detaillierte Anamnese vor und nach der Antirefluxoperation mit besonderer Würdigung der klinischen Symptomatik. Die Daten der präoperativen Funktionsdiagnostik sollten in die Re-Evaluierung einbezogen und mit den aktuellen Befunden verglichen werden. Dies bedeutet zum einen eine Analyse der Indikationskriterien des Ersteingriffes und zum anderen eine Analyse möglicher fortgeschrittener oder neu entwickelter Funktionsdefekte. Grundsätzlich bleiben die Indikationskriterien zur Operation in einer Rezidivsituation unverändert. Darüber hinaus können auch symptomatische Funktionsstörungen, welche durch eine Antirefluxoperation ausgelöst wurden, eine Operationsindikation darstellen.
Indikation zur Re-Operation: Im Falle eines Refluxrezidives sprechen 3 wesentliche Kriterien für einen Wiederholungseingriff: 1. progressive Form der Erkrankung (nachgewiesene Schäden und Funktionsdefekte, Nachweis einer anatomischen Veränderung (Hiatushernie), Präsenz typischer Refluxsymptome, Nachweis einer PPI-Dosissteigerung), 2. nicht-säureabhängige Symptome trotz adäquater Medikation (Aspiration, Volumen-Reflux, Regurgitationen, pulmonale Symptome) und 3. Alternative zu einer medikamentösen Langzeit-Therapie (Bevorzugung, Abhängigkeit, Nebenwirkungen, Lebensqualität). Zusätzlich ergeben sich spezifische Indikationskriterien aufgrund symptomatischer mechanischer Probleme im ösophagogastralen Übergang durch ein Auflösen der Fundoplikatio-Manschette, ein Durchrutschen der Manschette (sogenannter „slipped-Nissen“), eine paraösophageale Hernierung und eine transhiatale Migration der intakten Manschette. Zudem können eine primär falsche Konstruktion der Manschette und eine nicht erkannte Ösophagusmotilitätsstörung ein wesentliches Indikationskriterium für einen Wiederholungseingriff darstellen.
Schlussfolgerung: Eine Entscheidung zur Indikationsstellung für eine Wiederholungsoperation sollte stets die Abwägung der symptomatischen Beeinträchtigung und der funktionsdiagnostischen Analyse zur Grundlage haben. Nur so kann die gegenüber jedem Ersteingriff geringere Erfolgsrate eines Wiederholungseingriffes verantwortungsbewusst den betroffenen Patienten erklärt und überantwortet werden.

Abstract

Background: Early function diagnostics and problem-oriented management are basic requirements in cases of functional problems and complications following antireflux surgery for gastroesophageal reflux disease (GERD).
History, Diagnostics, and Therapeutic Management: A detailed history with a focus on the development of symptoms before and after the initial antireflux operation are fundamental prerequisites for a good diagnostic work-up. The data of preoperative function tests should always be reconsidered when re-evaluating a patient and be compared to the current findings. Thus, an analysis of the indications of any previous antireflux operation and an analysis of potential new or aggravated functional defects are essential. The general criteria indicating an operative procedure in gastroesophageal reflux disease do not change following such operation. Beyond these, symptomatic functional disorders caused by an antireflux operation may represent a new indication for an operative revision.
Indication for Re-Operation: In the case of a symptomatic reflux recurrence, three essential criteria indicate an operative procedure: (i) a progressive type of GERD (proven functional defects, hiatal hernia, presence of typical reflux symptoms, necessity of increasing PPI dosage), (ii) non acid-dependent symptoms in spite of adequate medication (aspiration, volume reflux, pulmonary symptoms) and (iii) an alternative to medical therapy (preference, dependence, side effects, quality of life). In addition to these, symptomatic mechanical problems are important additional criteria for a redo procedure: the dissolution of the fundoplication wrap, the telescope-like slippage of the fundoplication around the proximal stomach (“slipped Nissen”), a paraesophageal herniation, and the transhiatal migration of an intact fundoplication. Finally, the rather seldom occurring wrong construction of the fundoplication and a not detected primary motility disorder (e. g., achalasia) are indications for redo surgery in most cases.
Conclusion:The decision for any redo surgery following antireflux operations should always be based on a sound balance between symptomatic impairment and objective findings in functional disorders. This analysis allows for a responsible decision process since any redo surgery holds the risk of a lower success rate than the initial operation.

Schlüsselwörter

gastroösophageale Refluxkrankheit - Rezidiv - Fundoplikatio - Re-Operation - Abdominalchirurgie - Viszeralchirurgie

Key words

gastroesophageal reflux disease - recurrence - fundoplication - re-operation - abdominal surgery - visceral surgery

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