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DOI: 10.1055/s-0031-1283982
Reflux-Rezidiv … und andere Probleme nach Fundoplikatio: Indikation zur Re-Operation
Reccurent Reflux … and Other Problems Following Fundoplication: Indication for Re-OperationPublikationsverlauf
Publikationsdatum:
21. Mai 2012 (online)
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.
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