Redo Surgery: Dor (Anterior) Fundoplication Following Trans-Oral Incision-Less Fundoplication (TIF)

Introduction: As the demand for minimally invasive approaches increases, patients can choose from a spectrum of risk-benefit profiles. For symptomatic reflux disease laparoscopic fundoplication remains the gold standard treatment. Yet with the advent of trans-oral incision-less fundoplication (TIF), some may attempt this as a first procedure where initial tests suggest the absence of a hiatal hernia, as it does not involve invasive surgery. Thus, the market for surgeons willing and able to take on redo anti-reflux work will only grow, as well as the need to understand and plan for these operations. This video illustrates one such case. Materials and Methods: Our 47-year-old female patient had worsening dysphagia and reflux symptoms despite her TIF 2 years prior. High-resolution esophageal manometry was normal by Chicago classification version 4. pH Studies showed prolonged duration of acid exposure in the esophagus (13.2%), DeMeester score 62.75, 14 reflux episodes were reported by the patient with a Symptom Association Probability of 95.3%. Barium swallow suggested a small hiatal hernia with reflux of contrast into the esophagus. Preoperative endoscopy showed only a single TIF fastener left intraluminally and a small hiatal hernia. For the operation she was placed in a modified Lloyd-Davies position with a head-up tilt at 45 degrees. The lead operator stood between the legs and the assistant to the patient’s right. The stack was sited to the patient’s left with the screen swung on the “arm” to face the lead operator (from above the patient’s head) for optimal ergonomics. Two 10 mm ports, two 5 mm ports, and a 5 mm trocar to insert Nathanson’s retractor were used. A right-to-left approach to dissection was used in anticipation of any scar tissue distorting planes toward the left crus. The tract created by the H-fasteners of the failed TIF was identified and a tractotomy was performed, systematically taking down scar tissue with hook diathermy and removing the extraluminal component of the fasteners. Notably the fasteners were not within the gastric lumen at all, contrary to how the results of the TIF procedure are advertised. It brings up the question of whether this is an isolated failure or the reality of the technique’s limitations. A Dor (anterior) fundoplication was then constructed in the usual way. Results: The patient was discharged on postop day 2 once her pain was controlled with oral analgesia. She had one re-admission via our A&E on postoperative day 19 for epigastric pain and “dry-retching” episodes, where an oral contrast CT study showed an intact, uncomplicated repair, and was discharged following symptom control. At telephone follow-up on postop week 6 her postop symptoms had markedly improved. At the 8-month mark she was still free of reflux symptoms and expressed satisfaction at the procedural result. Conclusion: Redo fundoplication following TIF can be safely taken on by Benign Upper GI surgeons experienced in anti-reflux surgery within the resources of a UK NHS District General Hospital. Consent: The authors have received and archived patients’ consents for video recording/publication in advance of video recording of the procedure. Source of work: This redo case was one of the patients on our NHS elective waiting list. The workload of this department includes redo benign hiatal surgery. There are no conflicts of interest. Author disclosure statement: The authors have no commercial affiliations that create a conflict of interest in connection with this video. The authors have received and archived patient consent for video recording and publication in advance of video recording of procedure.” Patient commentary on having the procedure done given 9 months post procedure. “In terms of reflux, that appears to have completely resolved and I can eat again—after over 5 years of severe issues it is wonderful to have finally had the reflux issue resolved. I am very pleased to have had the surgery and if I was in the same position would definitely say yes again.” Runtime of video: 10 mins.