CONTACTS
SUBJECTS
EGD Dilation LESV 141107 Triamcinalone Injection Effective Swallowin
1503 -
1503 - ..
1504 - Summary/Objective
1505 -
150501 - Follow up ref SDS 40 0000. ref SDS 33 0000.
150502 -
150503 -
150504 -
150505 -
150507 - ..
1506 -
1507 -
1508 - Background
1509 -
150901 - Progress Notes have been missing longer than 4 months, from the VA
150902 - computer that stores patient medical records, for the EGD procedure on
150903 - 141107 0800. ref SDS 31 SY6M Last night checked again and found they
150904 - are still missing, despite notice to the doctor on 141125 0942.
150905 - ref SDS 32 OL6F
150907 - ..
150908 - On 150116 0813 met with Jessica at GI Clinic VA Medical Center in
150909 - Sacramento, she has notified Doctor Lee that Progress Notes are
150910 - missing for EGD Dilation on 141107, ref SDS 35 MX5I; later that day at
150911 - 0922 Doctor Lee called and left voicemail message that his Progress
150912 - Notes for the EGD Dilation procedure on 141107, are missing from VA
150913 - medical records computer system; he further said the missing Progresss
150914 - Notes can be restored by scanning another source; he will have the
150915 - records restored and submit notice to the patient when his Progress
150916 - Notes can be downloaded using the Internet to access the VA computer
150917 - system. ref SDS 34 ZX6I
150919 - ..
150920 - On 150116 0813 at 0922 Doctor Lee called and left voicemail message
150921 - that his Progress Notes for the EGD Dilation procedure on 141107, are
150922 - missing from VA medical records computer system; he further said the
150923 - missing Progresss Notes can be restored from scanning another source;
150924 - he will have the records restored and submit notice to the patient
150925 - when his Progress Notes can be downloaded using the Internet to access
150926 - the VA computer system. ref SDS 34 ZX6I
150928 - ..
150929 - On 150120 1636 letter to Doctor Lee confirms understandings meeting
150930 - with Jessica on 150116, and voicemail message from Doctor Lee later on
150931 - 150116, saying he will post Progress Notes for EGD Dilation procedure
150932 - on 141107. ref SDS 36 VE95
150934 - ..
150935 - On 150130 1609 called and left message for Jessica to follow up again
150936 - with Doctor Lee to post Progress Notes for EDG Dilation procedure at
150937 - VA Sacramento Medical Center on 141107. ref SDS 37 MX5I
150939 - ..
150940 - On 150211 1239 called EGD Department VA in Sacramento and talked to
150941 - Jennifer; she coordinated with Jessica and recommended scheduling
150942 - meeting with Doctor Lee on preparing Progress Notes, ref SDS 39 6J9L,
150943 - for the meeting with the doctor to perform EGD dilation procedure on
150944 - 141107. ref SDS 31 K37G
150945 -
150946 -
150948 - ..
1510 -
1511 -
1512 - Progress
1513 -
151301 - Used c16 for notes on agenda issues...
151302 -
151303 - 1. Swallowing continues without problems past 4 months since EGD
151304 - dilation on 141107 0800. ref SDS 31 7V6I Triamcinalone
151305 - injection has been effective aiding swallowing, including
151306 - previously difficult to swallow meats. ref SDS 31 6P6G
151308 - ..
151309 - Hiking 11 miles per day aids digestion. Large quantities of
151310 - orange juice (750 ML per day) combined with lemmon juice grape
151311 - juice (about 100 ML each) and soft drink (Squirt or Doctor
151312 - Pepper) have helped increase HDL from 30 to 70, shown in recent
151313 - lab on 150209 1012. ref SDS 38 RY6O
151315 - ..
151316 - Can this level of organge juice and lemon juice effect
151317 - digestion system?
151319 - ..
151320 - Doctor Lee said orange juice, Lemmon and grape juice do not cause
151321 - harm to stomach and digestion system. He advised that orange juice
151322 - and lemmon juice aid digestion process.
151323 -
151324 -
151325 -
1514 -
SUBJECTS
Schedule Next EGD Dilation 150421 1300 Improve Health Care Case Mana
4103 -
410401 - ..
410402 - Schedule Next EGD Dilation 150421 1300
410403 - Procedure Review Meetings Helpful Schedule Follow Up 140521
410404 -
410405 -
410406 - Agenda continues...
410407 -
410408 - 2. Schedule next EGD dilation OA 150420??? - approximately 6
410409 - months after procedure on 141107.
410411 - ..
410412 - Last time notified doctor need EGD dilation OA 4 months due to
410413 - difficult swallowing. This was evenntually scheduled 7 months
410414 - after prior procedure. Hoping for 6 months interval this time.
410416 - ..
410417 - After the meeting, we went to Jessica's office.
410419 - ..
410420 - Doctor Lee assisted Jessica in scheduling meetings based on his
410421 - travel schedule.
410423 - ..
410424 - Scheduled next meeting for EGD Dilation procedure on 150421 1300
410426 - ..
410427 - Doctor Lee said these consultation meetings are helpful, so we
410428 - scheduled a consultation meeting about 6 weeks after the procecure on
410429 - 150421; it will be on 150521 0800.
410431 - ..
410432 - Doctor Lee advised that using this SDS record with customer's notebook
410433 - computer to guide the agenda for the meeting today, makes navigating
410434 - patient's 10 year medical history efficient for working with complex
410435 - issues. He asked how all the connections are created that instantly
410436 - provide precise access to relevant details from among weeks, months
410437 - and years of data?
410439 - ..
410440 - This aligns with Doctor Zipperstein's comments on SDS records saving
410441 - time and money improving medical case management, reported at Kaiser
410442 - on 940728 1943. ref SDS 1 0001 Month's later, Doctor Zipperstein
410443 - requested telephone conference using SDS records rather than schedule
410444 - meeting, reported on 940920 1132. ref SDS 2 5922
410446 - ..
410447 - Doctor Sandhu in Primary Care at VA Clinic in Martinez reported using
410448 - the Internet provides efficient communication to coordiate across VA
410449 - jurisdictions. The doctor described navigating patient history in SDS
410450 - records on the Internet is "pretty slick" saving time following heart
410451 - surgery, reported on 100104 0930. ref SDS 8 YM7N
410453 - ..
410454 - Today, Doctor Lee submitted a new email address to confirm
410455 - understandings for effective collaboration within the doctor patient
410456 - partnership....
410459 -
410460 -
410461 -
410462 -
410463 -
4105 -
SUBJECTS
Acid Burn LESV Stricture Swallowing Problems Increased Because Fundo
5203 -
520401 - ..
520402 - Ulceration Acid Burn LESV Fundoplication Failed Causing Hiatal Hernia
520403 - Fundoplication Failed Cause Hiatal Hernia Ulceration LESV Needs Surgical Repair
520404 - Surgical Repair Fundoplication Resolve Ulceration LESV and Hiatal Hernia in Stomach
520405 -
520406 -
520407 - Agenda continues...
520408 -
520409 - 3. Nurses Procedure handwritten notes for EGD dilation proc on
520410 - 141107, say at the bottom in part...
520411 -
520412 - Bx'd ulcer site & esophagus at 29 cm
520414 - ..
520415 - Is this another way of saying the doctor biopsied the LESV
520416 - stricture, which is a routine part of EGD procedure, as listed
520417 - in the record on 141107 0800. ref SDS 31 S36I
520419 - ..
520420 - Is this a new issue?
520422 - ..
520423 - What was the result of the biopsy?
520425 - ..
520426 - Doctor Lee seemed to say there are 2 issues. Dilation stretches the
520427 - LESV to enable normal swallowing. However...
520428 -
520429 - 1. Acid burn causes LESV to gradually constrict (increasing
520430 - stricture) over weeks and months following dilation
520431 - procedure due to reflux from stomach digestion process.
520432 - This causes rising swallowing problems.
520434 - ..
520435 - 2. Acid burn also causes ulceration at same LESV stricture
520436 - location due to reflux from stomach digestion process.
520438 - ..
520439 - The doctor showed traces of ulceration in photograph #4 taken during
520440 - EGD dilation on 141107. ref SDS 31 H19J
520441 -
520445 - ..
520446 - Omeprazole is prescribed to prevent "acid burn" problems from stomach
520447 - reflux by supplementing fundoplication. Doctor Stewart constructed
520448 - fundoplication during Heller Myotomy surgery to treat achalasia on
520449 - 091216. ref SDS 7 KE9U (see Progress Notes received in the record a
520450 - year later on 100928 0706, ref SDS 11 VK8F). During the meeting at
520451 - the VA Medical Center in San Francisco on 091030, Doctor Stewart
520452 - planned fundoplication to fold stomach tissue for preventing acid
520453 - reflux flow from the stomach through LESV. ref SDS 6 OY64
520455 - ..
520456 - Doctor Lee explained that in the past year or so, fundoplication
520457 - surgically constructed 5 years ago, has unraveled. He cited
520458 - photograph #4 as showing failed fundoplication, taken during EGD
520459 - dilation on 141107, listed in Progress Notes. ref SDS 31 H19J
520460 -
520461 - F:\05\00003\SM\CC\AGMJ\20141107-080000\EGD-11_07_2014-10_19-04-photograph.pdf
520463 - ..
520464 - Doctor Lee placed this photograph next to another taken 3 or 4 years
520465 - earlier, which seemed to show stomach tissue swirled or wrapped with
520466 - many wrinkles near the LESV. He compared this with the picture taken
520467 - during the EGD procedure on 141107, which seems much flatter, with
520468 - less swirls and wrikles. This same comparison holds for photographic
520469 - records of EGD dilation just a year earlier on 131115. ref SDS 24 UP7F
520471 - ..
520472 - F:\05\00003\SM\CC\AGMJ\20131115-080024\Welch_11-22-13-photograph.docx
520474 - ..
520475 - At that time on 131115, Progress Notes report "Fundoplication remains
520476 - intact." ref SDS 24 JW4I However, a year later on 141107, the
520477 - photograph seems markedly different.
520479 - ..
520480 - The doctor advised that Findings of "ulceration" and "Hiatal hernia"
520481 - in Progress Notes on 140509, ref SDS 27 P396, correlates with failure
520482 - of fundoplication, as set out in Impressions from Progress Notes on
520483 - 140509 0900. ref SDS 27 I93F
520485 - ..
520486 - This failure of the fundoplication system constructed by Doctor
520487 - Stewart on 091216, now allows more acid reflux to pass through LESV,
520488 - which Omperazole alone cannot resolve.
520490 - ..
520491 - Increased acid burn caused ulceration due to failure of fundoplication
520492 - may have begun OA time of EGD Dilation on 140509, when hiatical hernia
520493 - was first reported, ref SDS 27 P34O, that indicated loosening of
520494 - fundoplication. ref SDS 27 I93F Progress Notes for prior procedure do
520495 - not report ulceration, hiatical hernia, nor loosening of
520496 - fundoplication, reported in findings on 131115 0700. ref SDS 24 PY6O
520497 -
520498 - [On 150421 1210 EGD Dilation examination found ulceration
520499 - on LESV appears less severe, i.e., improved. ref SDS 43
520500 - QQ7N Progress Notes found ulcerations regressing
520501 - (improving) to mere erosions. ref SDS 44 PXXY
520503 - ..
520504 - Doctor Lee explained that fundoplication was initially considered very
520505 - successful, but, like the instant case, eventual failures have been
520506 - reported in the medical literature. After the meeting today, research
520507 - found June 2005 NIH article in "Anals of Surgery" and titled "When
520508 - Fundoplication Fails Redo?" ref SDS 0 RI3M
520510 - ..
520511 - Patient requested Doctor Lee refer findings to Doctor Stewart from the
520512 - procedure on 141107, showing fundolplication issues may be causing
520513 - swallowing problems, per above. ref SDS 0 N46G Patient can inquire on
520514 - referral about new procedures to correct the problem, including
520515 - possibly re-doing fundoplication in order to reduce acid reflux to a
520516 - level that avoids continung ulceration and constriction of LESV
520517 - causing swallowing problems that require repeated EGD dilation
520518 - procedures.
520519 -
520520 - [On 150420 1752 letter submits agenda for meeting on
520521 - 150421, to review referral to Doctor Stewart to remedy
520522 - failed fundoplication. ref SDS 42 WL4O
520524 - ..
520525 - [On 150421 1210 Progress Notes for EGD Dilation procedure
520526 - recommendations cite referral to San Francisco Surgical
520527 - Clinic for consideration of repeat fundoplication.
520528 - ref SDS 44 KT69
520530 - ..
520531 - [On 150514 0130 letter to Doctor Lee requests file Progress
520532 - Notes for EGD Dilation today, and make referral to Doctor
520533 - Stewart, to prepare for meeting with Doctor Lee scheduled
520534 - on 150521. ref SDS 45 K37G
520536 - ..
520537 - [On 150514 0130 at 1326 received call from VA Medical
520538 - Center in San Francisco and scheduled meeting with Doctor
520539 - Stewart in General Surgery to review "redo" fundoplication
520540 - to recover from surgery failure in order to prevent
520541 - recurrence and compounding of ulcerations on LESV that
520542 - worsen achalasia swallowing problems. ref SDS 45 US53
520543 -
520544 -
520545 -
520546 -
5206 -
SUBJECTS
Progress Notes Received EGD Dilation 141107 LESV Contracted 15mm Bec
6103 -
610401 - ..
610402 - Progress Notes Received EGD Dilation 141107 LESV Contracted 15mm
610403 -
610404 -
610405 - Agenda continues...
610406 -
610407 - 4. Progress Notes for meeting on 141107 0800. ref SDS 31 CY7I
610408 -
610409 - On 150116 0813 at 0922 Doctor Lee called and left voicemail
610410 - message that his Progress Notes for the EGD Dilation procedure
610411 - on 141107, are missing from VA medical records computer system;
610412 - he further said the missing Progresss Notes can be restored
610413 - from scanning another source; he will have the records restored
610414 - and submit notice to the patient when his Progress Notes can be
610415 - downloaded using the Internet to access the VA computer system.
610416 - ref SDS 34 ZX6I
610418 - ..
610419 - During the meeting today, Doctor Lee showed his Progress Notes for the
610420 - prior EGD Dilation procedure on 141107. He said they were completed
610421 - and posted yesterday, and so should be available for the patient to
610422 - download within a few days.
610424 - ..
610425 - The doctor noted Progress Notes report LESV contracted from 18 mm to
610426 - 16.5 mm. There was brief discussion that 1.5 mm seems conflicting
610427 - with record of increased swallowing problems during the prior period,
610428 - cited in requests to the VA for early dilation, e.g., on 140810 1839,
610429 - ref SDS 29 W83K, and again, 141103 2152. ref SDS 30 K37G We reviewed
610430 - patient record of post-procedure meeting on 141107, showing Doctor Lee
610431 - seemed to advise that LESV contracted 3 mm from 18 mm down to 15 mm,
610432 - consistent with severe swallowing problems experienced prior to
610433 - dilation back to 18 mm. ref SDS 31 6P6G Contraction to 15 mm on
610434 - 141107, appears consistent with patient history of prior LESV
610435 - dilations when triamcinolone was not injected, as occurred on
610436 - 140509...
610438 - ..
610439 - LESV Dilated
610440 - Date from - to
610441 - 141107 15 18.....triamcinolone.... ref SDS 31 P680
610442 - 140509 16.5 18...................... ref SDS 27 P680
610443 - 131115 16.5 18.....triamcinolone.... ref SDS 24 RZ45
610444 - 130416 18 18.....triamcinolone.... ref SDS 23 Y850
610445 - 130110 15 18.....triamcinolone.... ref SDS 20 Q333
610446 - 120925 15 18.....triamcinolone.... ref SDS 18 XB51
610447 - 120322 16.5 18...................... ref SDS 17 516N
610448 - 111115 16.5 18...................... ref SDS 16 IR57
610449 - 110819 15 16.5...triamcinolone.... ref SDS 15 J978
610450 - 110429 13 16.5...triamcinolone.... ref SDS 14 U23I
610451 - 110218 11 14.....triamcinolone.... ref SDS 13 AA5O
610452 - 101210 11 14...................... ref SDS 12 H347
610453 - 100827 11 15...................... ref SDS 10 JE6X
610454 - 100305 11 15...................... ref SDS 9 WR6L
610455 -
610456 -
6105 -
SUBJECTS
CT Test Esophagus Recurrance Achalasia Hiatal Hernia Referral Doctor
7403 -
740401 - ..
740402 - CT Test Esophagus and Coronary CTA
740403 -
740404 -
740405 - 5. CT test evaluate esophagus and adding coronary CTA with
740406 - calcium score.
740408 - ..
740409 - Previously, on 130108, Doctor Lee ordered a CT test, ref SDS 19 8H4K,
740410 - to evaluate recovery from achalasia swallowing problems. Earlier on
740411 - 051202, Doctor Lee diagnosed achalasia noting a large bulge in the
740412 - esophagus caused by failure of LESV function to enable normal
740413 - swallowing, ref SDS 4 5B5K, shown in prior CT testing on 050714 1000.
740414 - ref SDS 3 2I9J On 091216, Doctor Stewart performed Heller Myotomy
740415 - surgery at VA Medical Center in San Francisco, intended to resolve
740416 - achalasia. ref SDS 7 KE9U
740418 - ..
740419 - On 130110, Doctor Lee performed EGD Dilation procedure, ref SDS 20
740420 - 134H, continuing supplemental care beginning after surgery, as
740421 - follows...
740422 -
740423 - LESV Dilated
740424 - Date from - to
740425 - 130110 15 18.....triamcinolone.... ref SDS 20 Q333
740426 - 120925 15 18.....triamcinolone.... ref SDS 18 XB51
740427 - 120322 16.5 18...................... ref SDS 17 516N
740428 - 111115 16.5 18...................... ref SDS 16 IR57
740429 - 110819 15 16.5...triamcinolone.... ref SDS 15 J978
740430 - 110429 13 16.5...triamcinolone.... ref SDS 14 U23I
740431 - 110218 11 14.....triamcinolone.... ref SDS 13 AA5O
740432 - 101210 11 14...................... ref SDS 12 H347
740433 - 100827 11 15...................... ref SDS 10 JE6X
740434 - 100305 11 15...................... ref SDS 9 WR6L
740436 - ..
740437 - On 130117 VA performed CT barrium swallow test ordered by Doctor Lee.
740438 - ref SDS 21 LM8K This test showed the esophagus had fully recovered on
740439 - 130117. ref SDS 21 OH6G
740441 - ..
740442 - This favorable test result was reviewed by Doctor Stewart during a
740443 - meeting at the VA in San Francisco on 130122 1330. ref SDS 22 03H6 At
740444 - that time, Doctor Stewart was pleased to see full recovery,
740445 - ref SDS 22 UM5L, 4 years after she performed Heller Myotomy surgery
740446 - on 091216, to correct grossly deformed esophagus and thereby relieve
740447 - severe swallowing problems.
740449 - ..
740450 - We discussed today, ordering a follow up CT test of the esophagus for
740451 - recovery from increased swallowing problems, per above. ref SDS 0 6P9M
740453 - ..
740454 - Doctor Lee will include in his letter to Doctor Stewart consideration
740455 - on ordering follow up CT test of the esophagus to evaluate recovery of
740456 - achalasia, along with review of correcting fundoplication issues, per
740457 - above. ref SDS 0 JQ5J
740459 - ..
740460 - Another CT test could include the chest and lower abdomen to check for
740461 - regression of atherosclerotic plaques. Doctor Stewart works with
740462 - Doctor Elaine Tseng, attending physician for CABG +4 surgery performed
740463 - on 091022. ref SDS 5 PQWU Doctor Tseng may be positioned to
740464 - collaborate on ordering coronary CTA with calcium score to assess
740465 - results from patient hiking 8,500 miles, summarized in case study on
740466 - 140101 0600. ref SDS 26 XY4M
740468 - ..
740469 - Hiking 11 miles per day has increased by 130% HDL 30 to HDL 70, over
740470 - the past 4 years shown in most recent labs on 150209 1012. ref SDS 38
740471 - W25L Research on 131125, indicates that exercise also increases EPCs,
740472 - and this combination of elevated HDL and EPCs can "rapidly" repair
740473 - damage to endothelial lining of blood vessels, commonly called
740474 - "atherosclerotic plaques." ref SDS 25 HG90
740476 - ..
740477 - If plaques are no longer evident in coronary CTA this may
740478 - justify reducing prescribed care hiking 300 miles per month, and
740479 - taking statin medications. Reducing level of care would save
740480 - considerable time and money, and also reduce onerous side effects of
740481 - daily medications.
740483 - ..
740484 - Doctor Lee requested research on regressing atherosclerosis and
740485 - testing with coronary CTA radiology.
740486 -
740487 - [On 150323 1926 letter to Doctor Lee provided access to
740488 - this record listing requested research on coronary CTA.
740489 - ref SDS 41 WV3H
740491 - ..
740492 - Following links present extracted research with narrative correlating
740493 - with patient history, and further linked to original articles...
740494 -
740495 - 1. On 131125, research indicated "rapid" regression of
740496 - atherosclerosis occurs with elevated HDL and EPCs (Endothelial
740497 - Progenitor Cells). ref SDS 25 6S7F
740499 - ..
740500 - Rapid regression of atherosclerosis: insights from the
740501 - clinical and experimental literature
740502 -
740503 - http://www.nature.com/nrcardio/journal/v5/n2/full/ncpcardio1086.html
740505 - ..
740506 - Nature Clinical Practice Cardiovascular Medicine (2008) 5,
740507 - 91-102
740508 - doi:10.1038/ncpcardio1086
740509 - Received 7 March 2007 | Accepted 17 October 2007
740511 - ..
740512 - Kevin Jon Williams*, Jonathan E Feig and Edward A Fisher*
740513 -
740515 - ..
740516 - 2. On 131125, research indicated endurance exercise increases HDL
740517 - and lowers triglycerides. ref SDS 25 U44L
740519 - ..
740520 - American Heart Association
740521 - Arteriosclerosis, Thrombosis, and Vascular Biology
740523 - ..
740524 - Effects of Endurance Exercise Training on Plasma HDL
740525 - Cholesterol Levels Depend on Levels of Triglycerides
740527 - ..
740528 - Received January 29, 2001.
740529 - Accepted April 6, 2001.
740530 -
740531 - http://atvb.ahajournals.org/content/21/7/1226.full
740532 -
740534 - ..
740535 - 3. On 131125, research indicated endurance exercise increases EPCs
740536 - required along with raising HDL for regression of
740537 - atherosclerosis plaques. ref SDS 25 8X4N
740539 - ..
740540 - American Heart Association
740542 - ..
740543 - Exercise in Cardiovascular Disease Cardiovascular Effects of
740544 - Exercise Training Molecular Mechanisms
740545 -
740546 - http://circ.ahajournals.org/content/122/12/1221.full#sec-34
740548 - ..
740549 - Stephan Gielen, MD; Gerhard Schuler, MD; Volker Adams, PhD
740551 - ..
740552 - Coronary CTA Standard of Care Test Response to Treatment CVD
740554 - ..
740555 - 4. On 140519 meeting with Doctor Alba at VA Medical Center in San
740556 - Francisco reviewed research sources on standard of care testing
740557 - response to treatment to reduce risk of CVD, using coronary CTA
740558 - with calcium score. ref SDS 28 OF7N
740560 - ..
740561 - See in particular para 4...
740563 - ..
740564 - Regression of coronary plaque after coronary artery bypass graft
740565 -
740566 - http://www.sciencedirect.com/science/article/pii/S1878540912000035
740567 -
740568 - ...and saying in part...
740570 - ..
740571 - Three years after treatment, 64-MDCT showed mild stenosis
740572 - and a regression of plaque in the LMT. The mean density of
740573 - the plaque was 73.1 HU (intermediate plaque) [...before
740574 - CABG and 32.4 after CABG; plaque size reduced from 20.7 to
740575 - 4.26...]
740576 -
740577 -
740578 -
7406 -
SUBJECTS
Progress Notes Meeting 150319 GI Clinic Gastroenterology Department
8403 -
840401 - ..
840402 - Progress Notes Meeting Today Gastroenterology Department VA Medical Center Sacramento
840403 -
840404 - Follow up ref SDS 31 CY7I, ref SDS 27 CY7I, ref SDS 24 CY7I.
840406 - ..
840407 - VA website is at...
840408 -
840409 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
840410 -
840416 -
840418 - ..
840419 - On 150418 found Progress Notes for meeting on 150319...
840421 - ..
840422 - F:\05\00003\SM\CC\AGMJ\20150319-080000\mhv_20150324_0607.pdf
840424 - ..
840425 - F:\05\00441\CG\GG\HMC\20150319-080000\mhv_20150324_0607.pdf
840427 - ..
840428 - F:\05\00441\SM\BGMC\20150319-080000\mhv_20150324_0607.pdf
840430 - ..
840431 - 1. LOCAL TITLE: Gastroenterology Attending F/U Note 60127
840432 - STANDARD TITLE: GASTROENTEROLOGY ATTENDING NOTE
840433 - DATE OF NOTE: MAR 19, 2015@08:00 ENTRY DATE: MAR 19, 2015@14:47
840434 - AUTHOR: LEE,RANDALL E EXP COSIGNER:
840435 - URGENCY: STATUS: COMPLETED
840437 - ..
840438 - 2. fu 1390582 reviewed prior egd report, requests query to dr.
840439 - stewart for consideration of repeat fundopliation discussed his
840440 - cad, requests ccta schedule routine egd & dilation
840442 - ..
840443 - Why is there no reference to prior Progress Notes on 140509, reporting
840444 - hiatal hernia caused by failed fundoplication, ref SDS 27 I93F, and
840445 - further discussed during the meeting today, per above? ref SDS 0 KN6F
840447 - ..
840448 - Progress Notes for meeting on 150319 continue...
840449 -
840450 - 3. /es/ Randall E. Lee, MD
840451 - Staff Physician, Gastroenterology
840452 - Signed: 03/19/2015 14:48
840453 -
840454 -
840455 -
840456 -
8405 -
SUBJECTS
Fundoplication Very Low 3% Failure Rate Research Internet NIH Annals
9903 -
9904 - 2213
990501 - ..
990502 - Fundoplication Very Low Failure Rate
990503 -
990504 - After the meeting this morning with Doctor Lee, research found article
990505 - on frequency of fundoplication failure, and indicating laparoscopic
990506 - surgery can successfully "redo" fundoplication so that acid reflux is
990507 - controlled with minimal medication, as planned during the meeting at
990508 - the VA on 091030 0810, ref SDS 6 OY69
990509 -
990510 - PMC
990511 - US National Library of Medicine
990512 - National Institutes of Health
990514 - ..
990515 - Annals of Surgery
990516 - A Monthly Review of Surgical Science Since 1885
990518 - ..
990519 - Ann Surg. 2005 Jun; 241(6): 861871.
990520 - PMCID: PMC1357166
990521 - doi: 10.1097/01.sla.0000165198.29398.4b
990523 - ..
990524 - When Fundoplication Fails Redo?
990525 -
990526 - C Daniel Smith, MD,* David A. McClusky, MD,* Murad Abu Rajad, MD,* Andrew B.
990527 - Lederman, MD, and John G. Hunter, MD!
990528 -
990529 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/
990531 - ..
990532 - 1. Abstract
990533 -
990534 - 1. Objective:
990535 -
990536 - The largest series in the literature dealing with redo
990537 - fundoplication was presented and published in 1999 and
990538 - included 100 patients. Herein we update this initial
990539 - series of 100, with 207 additional patients who have
990540 - undergone redo fundoplication (n = 307).
990542 - ..
990543 - 2. Summary Background Data:
990544 -
990545 - Increasing numbers of patients are failing esophagogastric
990546 - fundoplication and requiring redo procedures. Data
990547 - regarding the nature of these failures have been scant.
990548 -
990550 - ..
990551 - 3. Methods:
990552 -
990553 - Data on all patients undergoing foregut surgery are
990554 - collected prospectively. Between 1991 and 2004, 307
990555 - patients underwent redo fundoplication for the management
990556 - of anatomic complications or recurrent GERD. Statistical
990557 - analysis was performed with multiple Ç2 and Mann-Whitney U
990558 - analyses, as well as ANOVA.
990559 -
990561 - ..
990562 - 4. Results:
990563 -
990564 - Between 1991 and 2004, 1892 patients underwent primary
990565 - fundoplication for GERD (1734) or paraesophageal hernia
990566 - (158). Of these, 54 required redo fundoplication (2.8%).
990567 - The majority of failures (73%) were managed within 2 years
990568 - of the initial operation (P = 0.0001). The mechanism of
990569 - failure was transdiaphragmatic wrap herniation in 33 of 54
990570 - (61%). In the 231 patients who underwent fundoplication
990571 - elsewhere, 109 had transdiaphragmatic herniation (47%, P =
990572 - NS). In this group of 285 patients, 22 (8%) required
990573 - another redo (P = NS). The majority of the procedures were
990574 - initiated laparoscopically (240/307, 78%), with 20
990575 - converted (8%). Overall mortality was 0.3%.
990577 - ..
990578 - 5. Conclusions:
990579 -
990580 - Failure of fundoplication is unusual in experienced hands.
990581 - Most are managed within 2 years of the initial operation.
990582 - Wrap herniation has now become the most common mechanism of
990583 - failure requiring redo. Redo fundoplication was successful
990584 - in 93% of patients, and most could be safely handled
990585 - laparoscopically.
990586 -
990588 - ..
990589 - 2. Since its introduction in 1991,1 laparoscopic, ref SDS 24 F37N,
990590 - Nissen (360 degree) fundoplication has become the most widely
990591 - applied antireflux procedure accounting for 87 of every
990592 - 100,000 hospital discharges in 1999, according to the National
990593 - Inpatient Sample.2 This represents a near 8-fold increase for
990594 - this procedure over a 10-year period. The best outcomes with
990595 - 5-year or longer follow-up after Nissen fundoplication report
990596 - patient satisfactions of 86% to 96%, making the laparoscopic
990597 - Nissen fundoplication the gold standard for antireflux
990598 - procedures.38
990600 - ..
990601 - 3. Laparoscopic fundoplication has recently been called into
990602 - question.9-11 The rate of failure following fundoplication for
990603 - gastroesophageal reflux disease (GERD) varies from 2%-30%,
990604 - depending on how "failure" is defined; for example, failure
990605 - requiring resumption of medical therapy versus failure
990606 - requiring reoperation. Failure following Nissen fundoplication
990607 - for paraesophageal hernia also ranges from 7%-33%, depending on
990608 - whether failure is defined symptomatically or
990609 - anatomically.12-14 In select cases, fundoplication failure
990610 - requires revisional fundoplication (redo).
990612 - ..
990613 - 4. In 1996, we reported our experience with redo fundoplication in
990614 - 100 consecutive patients, detailing the pattern of failure and
990615 - outcomes with redo fundoplication.15 Herein, we detail our
990616 - updated experience with over 300 consecutive redo
990617 - fundoplications.
990619 - ..
990620 - 5. MATERIALS AND METHODS
990621 -
990622 - 1. Patients
990623 -
990624 - 1. The institution's institutional review board approved
990625 - this study. Data on all foregut patients undergoing
990626 - surgery are collected prospectively and maintained in a
990627 - computer database (Microsoft Access, Microsoft Corp,
990628 - Seattle, WA). Details on preoperative presentation and
990629 - symptoms, results from objective testing (typically,
990630 - barium swallow, esophagogastroduodenoscopy, ambulatory
990631 - esophageal pH testing, esophageal motility, and gastric
990632 - emptying), operative findings including
990633 - surgeon-documented mechanism of failure (herniated
990634 - fundoplication, disrupted fundoplication, slipped
990635 - fundoplication, crural stenosis/tight wrap, misplaced
990636 - fundoplication, and twisted fundoplication), and
990637 - postoperative course. When more than 1 failure
990638 - mechanism was identified intraoperatively, the most
990639 - prominent or causative mechanism was recorded as the
990640 - mechanism of failure (eg, fundoplication herniation
990641 - accompanied by fundoplication disruption was
990642 - categorized as a herniated fundoplication).
990644 - ..
990645 - 2. Postoperative symptom assessment was performed 1 month
990646 - after surgery and annually thereafter. Symptoms of
990647 - heartburn, dysphagia, and chest pain were assessed
990648 - using a 5-point scale (0, none; 1, mild; 2, moderate;
990649 - 3, severe; 4, intolerable).
990651 - ..
990652 - 3. Revisional surgery (redo fundoplication) is offered to
990653 - patients who have persistent, recurrent, or new foregut
990654 - symptoms (heartburn, dysphagia, chest pain,
990655 - regurgitation, asthma, hoarseness, chronic cough, or
990656 - laryngitis) and confirmed physiologic abnormalities or
990657 - a definable anatomic defect. Potential candidates for
990658 - redo fundoplication are evaluated for anatomic and
990659 - physiologic evidence of failure by selective use of
990660 - barium swallow, upper endoscopy, esophageal motility,
990661 - esophageal pH testing, and gastric emptying study. For
990662 - this study, preoperative diagnoses were assigned based
990663 - upon these objective evaluations, and all types of
990664 - fundoplication (partial or complete) and operative
990665 - approaches (open, laparoscopic, converted, or thoracic)
990666 - were included. Patients were excluded if their initial
990667 - operation was for the diagnosis of achalasia.
990669 - ..
990670 - 4. From October 1, 1991, to April 1, 2004, 1892 patients
990671 - underwent primary fundoplication at Emory for GERD (n =
990672 - 1734) or paraesophageal hernia repair (n = 158) (Fig.
990673 - 1). Of these, 54 patients required redo fundoplication
990674 - (2.8%). For purposes of comparison and data analysis,
990675 - these 54 patients have been grouped together (internal
990676 - primary fundoplication group, n = 54). During this
990677 - same time period, 231 patients underwent fundoplication
990678 - elsewhere and subsequently underwent redo
990679 - fundoplication at Emory. All patients who underwent
990680 - any redo fundoplication, either first redo or multiple
990681 - redos, prior to referral to Emory are grouped (external
990682 - fundoplication group, n = 231). From the combined
990683 - group of 285 patients (54 Emory patients and 231
990684 - external patients), more than 1 redo fundoplication was
990685 - necessary in 22 patients (multiple redos group, n = 22)
990686 - bringing the total number of redo fundoplications
990687 - performed during this time period to 307 redos in 285
990688 - patients. Stratified by number of redos, 241 patients
990689 - underwent 1 redo, 59 underwent 2 redos, 6 underwent 3
990690 - redos, and 1 underwent 4 redo fundoplications (Fig. 2).
990691 - Again, for comparing preoperative presentation and
990692 - operative findings for the first redos, those referred
990693 - after failure of primary fundoplication externally are
990694 - grouped (external primary fundoplication group, n =
990695 - 187).
990697 - ..
990698 - FIGURE 1. Antireflux surgery at Emory from 1992 through 2004.
990699 -
990700 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f1-3/
990702 - ..
990703 - FIGURE 2. Breakdown of patients undergoing redo fundoplication.
990704 -
990705 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f2-3/
990706 -
990708 - ..
990709 - 5. Follow-up
990710 -
990711 - 1. For the past 10 years, a full-time research nurse
990712 - has been maintaining Emory's foregut database. In
990713 - addition to collecting data from office visits, the
990714 - research nurse also contacts patients every 23
990715 - years by phone or mail and has them complete a
990716 - follow-up questionnaire. When a patient cannot be
990717 - found through the contact information maintained in
990718 - the database, an Internet search for the patient's
990719 - contact information is conducted. This is a paid
990720 - service and claims that if an individual cannot be
990721 - found, they do not want to be found.
990723 - ..
990724 - 2. With this follow-up strategy, follow-up information
990725 - is available on 88% of the study group (269/307).
990726 - However, over time the rate of follow-up decreases
990727 - significantly (Fig. 3). One year or longer
990728 - follow-up data are only available on 54% of
990729 - patients who are more than 1 year postoperative
990730 - (150/278). Median follow-up for the overall group
990731 - is 1.2 years (range, 93042 days).
990733 - ..
990734 - FIGURE 3. Number of patients with follow-up data available by year.
990735 -
990736 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f3-3/
990737 -
990739 - ..
990740 - 6. Statistics
990741 -
990742 - Statistical analysis was performed with multiple Ç2 and
990743 - Mann-Whitney U analyses, as well as ANOVA. Comparisons
990744 - of preoperative and postoperative data were made with
990745 - the Wilcoxon signed-rank test. Statistical significance
990746 - was set at P < 0.05 for each symptom.
990748 - ..
990749 - 6. RESULTS
990750 -
990751 - 1. Redo Clinical Presentation
990752 -
990753 - 1. Internal Primary Fundoplication (n = 54) Fifty-four
990754 - patients undergoing redo fundoplication had their
990755 - primary fundoplication at Emory for either
990756 - paraesophageal hernia (n = 10) or GERD (n = 40). In
990757 - this group, very few patients were experiencing
990758 - dysphagia (n = 8) or chest pain (n = 0) before their
990759 - first fundoplication (Table 1). While the new onset of
990760 - chest pain following fundoplication occurred in several
990761 - patients (n = 5), the most common new clinical finding
990762 - in patients requiring redo fundoplication was dysphagia
990763 - (15% prior to first fundoplication versus 56% prior to
990764 - redo; P < 0.05).
990766 - ..
990767 - TABLE 1. Clinical Presentation
990768 -
990769 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t1-3/
990771 - ..
990772 - 2. The majority of failures were managed within 2 years of
990773 - the initial operation (73%). Five patients underwent a
990774 - redo within 14 days after their primary
990775 - fundoplication. All 5 suffered immediate postoperative
990776 - nausea and retching followed by severe dysphagia, and
990777 - all underwent an immediate contrast swallow, which
990778 - revealed wrap herniation above the diaphragm. All were
990779 - immediately returned to the operating room for
990780 - reduction and repair of the hernia. None of these
990781 - patients went on to require another redo
990782 - fundoplication.
990784 - ..
990785 - 3. External Fundoplication (n = 231)
990786 -
990787 - The majority of patients in this series undergoing redo
990788 - fundoplication were referred from externally (n = 231)
990789 - after fundoplication for GERD (n = 198) or
990790 - paraesophageal hernia (n = 31). Forty-two patients
990791 - underwent 1 redo externally before referral, and 2
990792 - underwent 2 redos prior to referral (Fig. 2). Results
990793 - in patients undergoing multiple redos are detailed
990794 - later in the Multiple Redos section.
990796 - ..
990797 - 4. Presenting findings are detailed in Table 1 Compared
990798 - with the internal primary fundoplication group,
990799 - patients referred for redo fundoplication were more
990800 - likely to have recurrent GERD as the clinical
990801 - presentation for redo (60% of external versus 48%
990802 - internal primary fundoplication). Patients referred
990803 - were more likely to have a delayed presentation for
990804 - redo fundoplication, with 66% of patients in this group
990805 - having their redo fundoplication within 2 years of the
990806 - primary operation.
990808 - ..
990809 - 2. Patterns of Failure: Operative Findings
990810 -
990811 - 1. Internal Primary Redos (n = 54)
990812 -
990813 - In the 54 patients from Emory undergoing redo
990814 - fundoplication, 52 were initiated laparoscopically
990815 - (96%). Two were converted to open procedures due to
990816 - dense adhesions in the operative field, resulting in
990817 - 50/54 patients successfully undergoing laparoscopic
990818 - revisions (93%).
990820 - ..
990821 - 2. The reasons for failure as documented in operative
990822 - reports are detailed in Table 2. The majority of
990823 - failures fell into the categories of fundoplication
990824 - herniation, fundoplication disruption, slipped
990825 - fundoplication or tight wrap/crural stenosis. Only 2
990826 - failures were felt to be due to technical errors during
990827 - the first operation (1 twisted wrap and 1 misplaced
990828 - wrap).
990830 - ..
990831 - TABLE 2. Patterns of Failure (%)
990832 -
990833 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t2-3/
990835 - ..
990836 - 3. Eleven intraoperative complication were encountered in
990837 - 9 patients (17%) (Table 3). Two of the 4 patients
990838 - undergoing an open redo experienced an intraoperative
990839 - complication, and in both cases this was gastric
990840 - perforation.
990842 - ..
990843 - TABLE 3. Intraoperative Perforations (No.)
990844 -
990845 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t3-3/
990847 - ..
990848 - 3. External Primary Fundoplication (n = 187)
990849 -
990850 - 1. A laparoscopic approach was chosen for the 151 patients
990851 - whose initial fundoplication was performed
990852 - laparoscopically. Thirteen of these 151 laparoscopic
990853 - redos were converted to open procedures (8.6%). In 9 of
990854 - the 27 patients whose initial operation was open, the
990855 - redo was initiated laparoscopically, with 2 of these 9
990856 - being converted to open procedures (conversion rate
990857 - when first operation open, 22%). In this group, 77% of
990858 - the redos were successfully completed laparoscopically,
990859 - and the overall conversion rate was 9.4% (15/160).
990860 - Combining this with the internal primary fundoplication
990861 - group, the overall conversion rate was 8% (20/240).
990862 - All conversions were for dense adhesions at the
990863 - operative site.
990865 - ..
990866 - 2. As in the internal primary group, the most common
990867 - pattern of failure was fundoplication herniation.
990868 - There were also comparable other reasons for failure in
990869 - all categories except for misplaced fundoplications.
990870 - Significantly more patients who underwent
990871 - fundoplication externally were found to have a
990872 - misplaced wrap (2% internal versus 11% external; P<
990873 - 0.05). Figure 4 depicts the most common configuration
990874 - of the misplaced fundoplication, using the gastric body
990875 - for the wrap instead of the fundus.
990877 - ..
990878 - FIGURE 4. Most common configuration of a misplaced wrap.
990879 -
990880 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f4-3/
990882 - ..
990883 - 3. Forty-three operative complications occurred in 39
990884 - patients undergoing their first redo. Intraoperative
990885 - complications were more likely when the procedure was
990886 - converted from laparoscopic to open than for open or
990887 - laparoscopic alone (62% versus 17% and 17%; P < 0.05)
990888 - and in the overall group of 307 redos, gastric
990889 - perforation was the most common intraoperative
990890 - complication (Table 3).
990892 - ..
990893 - 4. Immediate Postoperative Outcomes (Total Group, n = 307)
990894 -
990895 - Postoperatively, 48 patients experienced 59 complications (14.7%).
990896 - Complications are detailed in Table 4. Complications were more common in
990897 - patients undergoing open redo fundoplication compared with those undergoing
990898 - laparoscopic redo (32.5% versus 10%, P < 0.05). Forty percent of those who
990899 - underwent conversion from laparoscopic to open redo suffered a complication
990900 - versus only 13% of those who had their operation completed laparoscopically
990901 - (8/20 versus 40/287; P < 0.05). One patient died of sepsis and multisystem
990902 - organ failure from pneumonia after an open redo. There was a trend toward an
990903 - increased complication rate as patients underwent multiple redos (see section
990904 - below on Multiple Redos).
990906 - ..
990907 - TABLE 4. Complications Following Redo Fundoplication, No. (%)
990908 -
990909 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/table/t4-3/
990910 -
990912 - ..
990913 - 5. Long-term Outcomes
990914 -
990915 - 1. Symptom Response
990916 -
990917 - 1. All patients underwent pre- and postoperative symptom
990918 - assessment for heartburn, dysphagia, and chest pain.
990919 - In addition, use and dosage of antisecretory
990920 - medications were recorded, as well as the need for any
990921 - postoperative interventions (EGD with dilation or more
990922 - surgery related to foregut problems).
990924 - ..
990925 - 2. Between 73% and 89% of patients reported their
990926 - postoperative symptoms of heartburn, dysphagia, and
990927 - chest pain to be absent or mild. Similarly, only 3%8%
990928 - of patients reported their symptoms postoperatively to
990929 - be severe, and no patients rated their symptoms as
990930 - intolerable. These postoperative findings were
990931 - significantly different than preoperative symptoms
990932 - (Fig. 5). While the majority of patients were
990933 - satisfied with their results, 16% were unsatisfied and
990934 - 14% were undecided.
990936 - ..
990937 - FIGURE 5. Pre- and postoperative symptom scores for A, heartburn, B,
990938 - dysphagia, and C, chest pain.
990939 -
990940 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f5-3/
990942 - ..
990943 - 3. At last follow-up, 17% of patients were using
990944 - antisecretory medications for GI symptoms. Eleven
990945 - percent underwent dilations postoperatively, and at
990946 - least 5 patients underwent redo fundoplication or
990947 - takedown of their fundoplications elsewhere. No
990948 - specific data are available for these patients.
990950 - ..
990951 - 2. Multiple Redos
990952 -
990953 - 1. Twenty-two patients who underwent a redo
990954 - fundoplication at Emory went on to have multiple
990955 - redos at Emory (Fig. 2). Five patients underwent
990956 - another redo externally. Since data on these
990957 - elsewhere redos are not available, they are not
990958 - included in this group's analysis. The rate of
990959 - second and third redo for patients was 7.1% and
990960 - 6.8%, respectively (P = NS), more than twice the
990961 - rate of revision for our primary fundoplication
990962 - group (2.8%, P < 0.05).
990964 - ..
990965 - 2. Mean time from first redo to second redo was 24 ±
990966 - 33 months, and from second to third redo, 12 ± 7
990967 - months. While 5 of the first redos were done for
990968 - acute wrap herniation during the same
990969 - hospitalization as the initial fundoplication, all
990970 - of the remaining second redos were for chronic
990971 - symptomatic failures.
990973 - ..
990974 - 3. Based upon objective testing, preoperative
990975 - diagnoses were compared between the first redo and
990976 - second redo groups. Findings of transdiaphragmatic
990977 - wrap migration and Barrett esophagus were more
990978 - common preoperatively in the second redo group.
990979 - There was also a trend away from recurrent GERD as
990980 - a preoperative diagnosis. Nearly one third of
990981 - patients had different preoperative findings at the
990982 - time of second redo than at the time of previous
990983 - operation, suggesting a new diagnosis and surgical
990984 - indication for the second redo procedure (Fig. 6).
990986 - ..
990987 - FIGURE 6. Preoperative findings comparing the first
990988 - failure with the second failed fundoplication.
990989 -
990990 - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1357166/figure/f6-3/
990992 - ..
990993 - 4. Operative details, including operative times, type
990994 - of approach, type of fundoplication, operative
990995 - findings, and complications, were compared between
990996 - the first and second redo groups. There were no
990997 - significant differences between groups in approach
990998 - or fundoplication type. A laparoscopic approach
990999 - predominated (74% in first redo versus 67% in
991000 - second redo), with conversion rates of 8% and 6%,
991001 - respectively. Conversions were usually due to
991002 - adhesions or, less commonly, enterotomy. The
991003 - majority were 360-degree fundoplications in both
991004 - groups, with approximately one fifth of patients
991005 - having partial fundoplications, reflecting the
991006 - preoperative incidence of esophageal-body
991007 - dysfunction. A gastrostomy tube, either operative
991008 - or PEG, was used in 17% of second redos, and a
991009 - Heller myotomy was used in 3.7% of second redos.
991011 - ..
991012 - 5. The gold standard for determining the cause of
991013 - fundoplication failure is the pattern of failure as
991014 - seen at the time of redo. A second revision in
991015 - those patients previously revised at our
991016 - institution was associated with a significantly
991017 - higher rate of fundoplication herniation compared
991018 - with the first redo group (72% versus 50%, P <
991019 - 0.05). The finding of a shortened esophagus was
991020 - similarly elevated in the second redo (2% versus
991021 - 17%, P < 0.05).
991023 - ..
991024 - 6. Those undergoing multiple redos did not experience
991025 - an increased risk of gastric perforation (14% first
991026 - redo versus 17% in second redo, P = NS) or
991027 - esophageal perforation (1.4% versus 5.6%, P = NS).
991028 - There was no perioperative mortality in the
991029 - multiple redo group.
991031 - ..
991032 - 7. Length of stay increased with each revision, from
991033 - 4.5 ± 3.4 days for the first redo to 5.8 ± 3.0 days
991034 - for second redo and 8.6 ± 3.7 days for those
991035 - undergoing a third redo fundoplication. There was
991036 - no difference in the rates of postoperative
991037 - dysphagia or use of dilation, but those undergoing
991038 - a second redo did have a higher rate of
991039 - antisecretory use after their surgery (12% versus
991040 - 23%; P < 0.05).
991042 - ..
991043 - 8. Using a univariate logistic regression, we looked
991044 - for risk factors at the time of first redo that may
991045 - predict the need for future surgery. The presence
991046 - of fundoplication herniation at the time of first
991047 - redo was the only significant predictor of the need
991048 - for another redo fundoplication, with an odds ratio
991049 - of 4. (95% CI 1.212.4).
991051 - ..
991052 - 7. DISCUSSION
991053 -
991054 - 1. Indications for Redo
991055 -
991056 - 1. Patients who present after a fundoplication with
991057 - persistent or recurrent foregut symptoms represent a
991058 - unique challenge. Increasing numbers of patients are
991059 - being diagnosed with GERD or paraesophageal hernia, and
991060 - with this, significant numbers of patients who in the
991061 - past would have lived with their foregut symptoms are
991062 - now receiving interventions. Since 1991, laparoscopic
991063 - antireflux surgery, in particular, the most widely
991064 - studied and applied operation, the Nissen (360-degree)
991065 - fundoplication, has seen an 8-fold increase in use.2
991066 - While largely successful when performed by surgeons
991067 - experienced in both laparoscopy and esophageal surgery,
991068 - even in the most experienced hands, surgery fails to
991069 - control the patient's symptoms or results in new
991070 - symptoms or anatomic problems in 3%-16% of
991071 - patients.5,11,16 Some type of revisional surgery may be
991072 - required in select patients.
991074 - ..
991075 - 2. In our practice, we consider redo fundoplication for
991076 - patients with persistent or recurrent foregut symptoms,
991077 - or in those who develop new foregut symptoms not
991078 - present before their initial fundoplication. Redo
991079 - surgery is offered to those who then have objective
991080 - evidence of failure based on physiologic studies or an
991081 - anatomic abnormality. Using this approach, we have had
991082 - to redo nearly 3% of our own fundoplications. We have
991083 - documented in other publications a higher redo rate in
991084 - those with more complicated GERD (Barrett, esophagitis,
991085 - and stricture).15-17 We have also documented a
991086 - symptomatic failure rate of 7% in those undergoing
991087 - fundoplication for paraesophageal hernia and an
991088 - anatomic failure rate of 33% in these same
991089 - patients.13,14 We do not offer a redo for patients with
991090 - anatomic failure in the absence of foregut symptoms.
991091 - In particular, we do not feel that a recurrent
991092 - paraesophageal hernia with its associated mediastinal
991093 - scarring has the same natural history as a primary
991094 - paraesophageal hernia. In our experience, we have never
991095 - seen an acute presentation for a recurrent
991096 - paraesophageal hernia not occurring in the immediate
991097 - postoperative period as a result of postoperative
991098 - retching! The most challenging patients have been
991099 - those with dysphagia, an anatomically normal-appearing
991100 - wrap, a normal barium swallow with a 12.5-mm tablet,
991101 - and normal esophageal pH and motility. These can be
991102 - very desperate patients whose desperation has led us to
991103 - reoperate. In fact, over half of the redos reported in
991104 - this paper were on patients with dysphagia. While most
991105 - of these patients also had anatomic reasons for their
991106 - dysphagia, several presented as described above, and we
991107 - have had some dramatically positive outcomes in these
991108 - patients, as well as some frustrating negative
991109 - outcomes. The Emory patient who underwent 4
991110 - fundoplications was one of these patients. He continues
991111 - to have dysphagia. Currently, we would not recommend
991112 - reoperation for a patient with dysphagia if an anatomic
991113 - or physiologic reason for dysphagia cannot be defined
991114 - preoperatively.
991116 - ..
991117 - 3. Another challenging patient group has been those with
991118 - recurrent heartburn or atypical symptoms, only mildly
991119 - abnormal esophageal pH studies, and no symptom
991120 - improvement with antisecretory medication. While redo
991121 - fundoplication may be warranted, there is a significant
991122 - potential to leave these patients with even worse
991123 - foregut symptoms. Before considering a redo in these
991124 - patients, we will document failure of acid suppression
991125 - with maximum-dose PPIs. The patient with heartburn
991126 - symptoms and appropriate acid suppression on PPIs
991127 - should not have a redo unless they cannot tolerate PPIs
991128 - due to severe side effects. The new endoluminal
991129 - approaches may offer an attractive alternative to redo
991130 - fundoplication for these patients. We have used this
991131 - approach in several patients, with satisfactory early
991132 - results.
991134 - ..
991135 - 2. Choice of Approach
991136 -
991137 - In our paper published in 1999, we detailed comparable
991138 - outcomes whether the redo operation was performed using an
991139 - open or laparoscopic approach. Our more recent experience
991140 - continues to support the utility of a laparoscopic approach
991141 - for redos, even when the initial fundoplications was open.
991142 - The conversion rate in those in whom a prior open
991143 - fundoplication was approached laparoscopically was 22%, and
991144 - overall 77% of redos in this series were completed
991145 - laparoscopically. At times a primary open redo is
991146 - selected, especially for patients whose prior foregut
991147 - surgery was complicated (eg, GI perforation with
991148 - perioperative abdominal sepsis or prior transthoracic
991149 - approach with chest complications). There was no increase
991150 - in intraoperative complications or postoperative
991151 - complications in the laparoscopic group. In fact, gastric
991152 - and esophageal perforation was more common in those
991153 - undergoing either primary open redo or converted to open
991154 - redo. This most likely reflects the complexity of the
991155 - cases that need to be performed with an open approach.
991156 - However, the laparoscopic group realized a lower incidence
991157 - of the postoperative complications of pneumonia, wound
991158 - infection, atelectasis and ileus. As our experience with
991159 - these operations has increased, we are infrequently using
991160 - an open approach, and over the past 23 months we have used
991161 - a primary open approach in only 4 of 48 patients (8%).
991163 - ..
991164 - 3. Technical Challenges
991165 -
991166 - 1. Reoperative esophageal surgery can be one of the most
991167 - challenging procedures that a GI surgeon will face.
991168 - Anatomy can be severely distorted by scarring,
991169 - fundoplication herniation, and unexpected findings.
991170 - Experience and knowledge of normal and abnormal anatomy
991171 - is critical to not only a safe operation but also
991172 - effective resolution of the patient's problems. This
991173 - experience documents a low rate of significant
991174 - complications and death despite the challenges of
991175 - reoperative foregut surgery.
991177 - ..
991178 - 2. The preoperative reason for failure is not always what
991179 - is found during surgery. In the external primary
991180 - fundoplication group undergoing redo fundoplication,
991181 - the preredo diagnosis was GERD in the majority of
991182 - patients. This would suggest that a loose wrap would
991183 - be found during surgery. In fact, several patients
991184 - were found to have twisted wraps without an
991185 - appropriately mobilized gastric fundus (short gastric
991186 - vessels intact) or misplaced or loose wraps (Fig. 5A,
991187 - B). Very few had simply a disrupted fundoplication. In
991188 - all cases, we take down the prior fundoplication and
991189 - redo the entire operation. In one patient with
991190 - dysphagia and a very normal-appearing wrap, after
991191 - complete mobilization of the fundoplication, a Penrose
991192 - drain was found wrapped around the distal esophagus.
991193 - In several other patients, unexpected foreign material
991194 - was found, including hernia tacks used for the crural
991195 - approximation and fundoplication and mesh when the
991196 - first operation mentioned nothing about hiatal hernia
991197 - or the use of mesh.
991199 - ..
991200 - 4. Diminishing Success With Each Redo
991201 -
991202 - Perhaps most significant is the data revealing a higher
991203 - rate of failure with a redo when compared with a first-time
991204 - fundoplication. While it is intuitive that the best
991205 - outcome will be with the first fundoplication, it is
991206 - perhaps surprising that the failure rate with 1 redo is
991207 - only 7.1% and not higher. This is, however, nearly 3 times
991208 - the redo rate after a first-time fundoplication. With a
991209 - third redo, the failure rate does not appear to increase,
991210 - but after 3 redos, it looks like the chance of subsequent
991211 - failure becomes prohibitive. While not detailed here, we
991212 - now seriously consider esophagectomy after 4 failures
991213 - (primary and 3 redos). Over the past 4 years, this has been
991214 - necessary in fewer than 10 patients. The only exception to
991215 - this is the patient who has a redo during which very
991216 - little is done (ie, more of an exploratory procedure than a
991217 - true attempted redo). Many patients have undergone a redo,
991218 - but at the time of another redo, virginal tissue plans are
991219 - encountered, suggesting a limited dissection in the
991220 - previous procedure.
991222 - ..
991223 - 5. Mechanism of Failure: Future
991224 -
991225 - 1. Fundoplication herniation was the most common mechanism
991226 - of failure in our 1999 series of 100 redos, and it
991227 - remains the most common mechanism of failure, even in
991228 - our own patients requiring redo fundoplication.
991229 - Clearly there is a need to better understand the
991230 - mechanics the esophageal hiatus and its reconstruction.
991231 - The etiology of this mechanism of failure is unclear.
991232 - Some have suggested that esophageal shortening
991233 - predisposes to fundoplication herniation and that an
991234 - esophageal lengthening should accompany all hiatal
991235 - hernia repairs. We have looked carefully at our own
991236 - experience with both the short esophagus and esophageal
991237 - lengthening and have found true esophageal shortening
991238 - to be unusual (<2% when assessed intraoperatively).
991239 - Esophageal lengthening, while providing an esthetically
991240 - pleasing intraoperative result, has resulted in
991241 - uncontrolled esophagitis or pathologic esophageal acid
991242 - exposure in 80% of patients postoperatively.18 Except
991243 - in the extreme situation, esophageal lengthening should
991244 - rarely be indicated. Another often-discussed issue is
991245 - the idea that hiatal hernias should be subjected to a
991246 - tension-free repair, as is now widely accepted for
991247 - abdominal wall hernias. Many are advocating routine use
991248 - of mesh for reconstruction of the esophageal hiatus.
991249 - Several prospective studies have documented improved
991250 - outcomes with mesh hiatoplasty; however, numbers are
991251 - small and follow-up is short.9 We have avoided mesh
991252 - except for the largest of hiatal defects due to
991253 - concerns about placing an inflammatory foreign body
991254 - next to the esophagus and our anecdotal experience in
991255 - several patients where mesh eroded into the esophagus
991256 - or caused significant esophageal stenosis. Clearly,
991257 - work needs to focus on improving our management of the
991258 - esophageal hiatus during fundoplication to improve the
991259 - results of this operation.
991261 - ..
991262 - 2. Finally, a comment about follow-up. As detailed
991263 - earlier, we have made a commitment to maintaining
991264 - contact with our patients through our full-time
991265 - research nurse and follow-up strategy. Even with such
991266 - efforts, follow-up is incomplete and extremely
991267 - difficult to maintain. After 1 year, just over half of
991268 - our patients respond to requests for follow-up. The
991269 - optimist and fundoplication enthusiast offers the
991270 - theory that in such a mobile society, most patients are
991271 - doing so well after this operation that they cannot be
991272 - bothered with follow-up. On the other hand, many
991273 - surgery enthusiasts have announced this theory only to
991274 - be dashed by a colleague in the room claiming to be
991275 - caring for increasing numbers of patients with
991276 - failures. As a quaternary referral center for foregut
991277 - conditions, we join the optimist group, hoping that if
991278 - significant numbers of our patients were requiring redo
991279 - surgery, the patients would be coming back to us or we
991280 - would hear about this from our colleagues. That being
991281 - said, the lack of objective long-term follow-up,
991282 - combined with an unclear definition of failure (back on
991283 - medication versus need for more surgery), continues to
991284 - fuel the debate over the role of fundoplication in the
991285 - management of the GERD patient, and this series does
991286 - not resolve the debate.
991288 - ..
991289 - 3. In summary, carefully selected patients who have
991290 - recurrent or persistent problems after fundoplication
991291 - can safely undergo redo fundoplication with good
991292 - results. In experienced hands, most patients can be
991293 - approached laparoscopically. Ideally, documented
991294 - long-term follow-up will allow continued evolution of
991295 - the care for the foregut patient, thereby providing
991296 - ever improving outcomes, but follow-up remains
991297 - problematic.
991299 - ..
991300 - 6. Discussions
991301 -
991302 - 4. Dr William O Richards (Nashville, Tennessee): Drs
991303 - Smith, Hunter, and colleagues are to be congratulated
991304 - on the significant work they have accomplished with
991305 - this report with redo Nissen fundoplications. I want
991306 - to emphasize several important aspects about their
991307 - experience.
991309 - ..
991310 - 5. Their results after redo operations are really
991311 - outstanding. They were able to perform the majority of
991312 - these redo operations laparoscopically with excellent
991313 - results and very low morbidity. In the manuscript, the
991314 - authors report five patients from their own experience
991315 - who presented with acute herniation of the intact wrap
991316 - in the early postoperative period that was related to
991317 - nausea and retching. Could the authors expand on these
991318 - cases and tell us if they were in any way related to
991319 - inadequate crural closure and if they recommend any
991320 - changes in the crural closure or postoperative care
991321 - that can decrease the risk of herniation?
991323 - ..
991324 - 6. Second, about half of their redo cases were related to
991325 - dysphagia in an angulated route, but 3.7% of the
991326 - patients undergoing a second redo operation underwent
991327 - Heller myotomy in the manuscript. Secondary achalasia
991328 - caused by the wrap occurs in a small number of patients
991329 - undergoing fundoplication at Vanderbilt. We believe
991330 - that takedown of the Nissen and performance of a Heller
991331 - myotomy is the best operation for these patients with
991332 - secondary achalasia. I would like to hear how you
991333 - handle the patients who have manometric findings of
991334 - achalasia after Nissen fundoplication.
991336 - ..
991337 - 7. Finally, about half the redo operations were performed
991338 - to alleviate recurrent GERD, but redo Nissen, even with
991339 - your excellent results, was associated with a
991340 - significant conversion rate, increased hospitalization,
991341 - and increased risk of another reoperation compared to
991342 - your primary operations. The new endoluminal therapies
991343 - may be able to improve the antireflux barrier
991344 - significantly and avoid performing a redo Nissen
991345 - fundoplication.
991347 - ..
991348 - 8. In patients with a partially disrupted wrap and
991349 - recurrent GERD but with no significant dysphagia, I
991350 - would preferentially perform a Stretta procedure or
991351 - another completely endoluminal therapy rather than
991352 - attempting a redo Nissen. I would be interested in
991353 - your thoughts as to which patients are best suited for
991354 - this approach.
991356 - ..
991357 - 9. Dr Blair A Jobe (Portland, Oregon): I wish to
991358 - congratulate Dr. Smith and his colleagues on this
991359 - excellent study and for assembling what is now the
991360 - largest series of reoperations for failed
991361 - fundoplication. The opportunity to gain insight into
991362 - the mechanisms by which our procedures fall down is
991363 - both valuable and rare.
991365 - ..
991366 - 10. The tremendous success of Nissen fundoplication has
991367 - been founded in the tenets of proper patient selection
991368 - and an adherence to the technical fundamentals of
991369 - reconstruction, that is, division of the short gastric
991370 - vessels, return of the esophagogastric junction into
991371 - the abdominal cavity, crural closure, and the creation
991372 - of a short floppy fundoplication around the distal
991373 - esophagus. Despite these advances in technique, a
991374 - small percentage of these patients will develop
991375 - recurrent symptoms and the need for revision as the
991376 - result of incompetence of the cardia, esophageal
991377 - obstruction, or both.
991379 - ..
991380 - 11. This study brings several important points to light.
991381 - First, similar to the findings of others, the most
991382 - common cause of failure resulting in reoperation was
991383 - herniation of the esophagogastric junction (with or
991384 - without the fundoplication) into the chest. Second,
991385 - the presence of fundoplication herniation at the time
991386 - of the first reoperation was a significant risk factor
991387 - for a subsequent failure, which would require another
991388 - operative repair. Third, the laparoscopic approach to
991389 - fundoplication failure results in good short-term
991390 - clinical outcomes and low morbidity in experienced
991391 - hands. Finally, failures, which are rare, occur within
991392 - 2 years of the primary operation. Based on these
991393 - findings, I have several questions.
991395 - ..
991396 - 12. Perhaps we have been too simplistic in how we
991397 - conceptualize herniation after fundoplication. The
991398 - age-old debate is whether herniation occurs as a result
991399 - of an unrecognized short esophagus, crural dehiscence,
991400 - or elements of both. Is it unrealistic to think that
991401 - we can place these dynamic and continually moving
991402 - structures adjacent to each other and not have some
991403 - element of herniation? The esophagus shortens with
991404 - each swallow and the diaphragm flattens with each
991405 - breath. This is bound to place stress on the crural
991406 - closure and fundoplication. With this in mind, should
991407 - Collis gastroplasty be used more liberally in the
991408 - primary operation, or is the risk for continued
991409 - esophageal injury too great? Did the majority of
991410 - patients that herniated have complicated reflux
991411 - (Barrett metaplasia, stricture) or a diaphragmatic
991412 - stressor? In light of your results, will you modify
991413 - your approach when herniation after a primary repair is
991414 - encountered?
991416 - ..
991417 - 13. From your data, it appears as if the incidence of the
991418 - malformed wrap is decreasing. In your study of
991419 - fundoplication failure in 1999, the most common cause
991420 - of failure in patients who were referred to Emory was a
991421 - twisted or slipped wrap. In the current study, the
991422 - referral consists primarily of patients with
991423 - herniation. Why do you think this pattern has shifted?
991425 - ..
991426 - 14. Finally, as Dr Richards brought up, is there a role for
991427 - endoscopic antireflux techniques in the tune-up of an
991428 - anatomically intact fundoplication which allows reflux?
991430 - ..
991431 - 15. Dr J David Richardson (Louisville, Kentucky): What do
991432 - you do with the occasional patient at the far end of
991433 - the spectrum who has had sort of a disastrous failure?
991434 - I have operated on several of these patients recently
991435 - where the entire fundoplication is in the chest and
991436 - nothing is working. Often, the wrap cannot be
991437 - anatomically returned to the abdomen with a laparoscope
991438 - or run open. What do you do with those patients who
991439 - are quite challenging? The authors stressed that
991440 - experienced hands are important in managing these
991441 - patients, but there is a lot of esophageal surgery
991442 - being done by relatively inexperienced surgeons.
991444 - ..
991445 - 16. Dr Robert V Rege (Dallas, Texas): I would like to
991446 - congratulate you on your paper. When you are done with
991447 - all of the redos and multiple redos, there is a
991448 - significant number of patients left over which are
991449 - troublesome for us because they show up at referral
991450 - centers. And those are the patients that do not have
991451 - physiologic or anatomic reasons to redo the wrap again
991452 - but continue to be dissatisfied with the results. I
991453 - would like to know how you handle these. Do you ever
991454 - take the wrap apart and give up on the reflux procedure
991455 - in those patients?
991457 - ..
991458 - 17. Dr C Daniel Smith (Atlanta, Georgia): Thank you for
991459 - these wonderful questions. As you might suspect, with
991460 - this experience we have struggled with a lot of these
991461 - same issues for years and years in managing these
991462 - patients.
991464 - ..
991465 - 18. Dr Richards asked questions about the 5 patients who
991466 - had acute wrap herniation and what we have done, if
991467 - anything, to try to manage that, and in particular, do
991468 - we do anything different with the crura?
991470 - ..
991471 - 19. In each of these cases, the patients experienced acute
991472 - postoperative retching. The first thing we have done
991473 - is implemented a policy of antinausea control and
991474 - antiemetics. We are very aggressive about all patients
991475 - getting preemptive nausea control. With that, in the
991476 - last 2 years we have not had any patients who have had
991477 - acute herniation and needed to go back to the operating
991478 - room. So I think retching prevention and nausea
991479 - prevention is number 1.
991481 - ..
991482 - 20. When you go back in on those few who have acute
991483 - herniation, it is hard to know what may have been
991484 - etiologic, if anything, at the time of the first
991485 - operation. Usually, there is a stitch that has popped
991486 - loose in the crura as the wrap has herniated. We have
991487 - not been able to determine any issues related to the
991488 - crura and how we handled the crura in those patients.
991490 - ..
991491 - 21. The second question had to do with myotomy and the
991492 - proposal of more liberal use of myotomy. We will do a
991493 - myotomy, but only if we can't find an anatomic basis at
991494 - the time of the second operation for esophageal outlet
991495 - obstruction, and the patient has aperistalsis on their
991496 - preoperative motility. In contrast, if we have any
991497 - element of preserved motility or body function and we
991498 - find a bit of a twist or tightness of the wrap, we will
991499 - not do a myotomy. That is why our myotomy rate is
991500 - fairly low. Again, we will apply it for the
991501 - aperistaltic esophagus when everything else looks
991502 - fairly normal.
991504 - ..
991505 - 22. Regarding the use of Stretta or endoluminal therapy
991506 - endoluminal therapy; absolutely, to both Drs. Jobe and
991507 - Richards. I think this is an application of
991508 - endoluminal therapy that I am probably most eager to
991509 - see developed, and we are doing it. Our preliminary
991510 - results are fairly favorable. Even if you can only
991511 - achieve acid control in 50% of patients with an
991512 - endoluminal therapy, that is half of the patients who
991513 - may not go on to the risks of a redo operation.
991514 - However, I think the endoluminal therapies are really
991515 - only appropriate for the patients who have recurrent
991516 - GERD and clear anatomic evidence of a disrupted wrap.
991517 - It is a fairly small number of patients, but I think
991518 - for those patients this is very appropriate.
991520 - ..
991521 - 23. Regarding Dr Jobe's question about complicated GERD, I
991522 - think the answer is yes, no question, the patients who
991523 - have Barrett esophagitis or stricture have an 8%
991524 - failure rate. But we have patients in this group who
991525 - also had herniation because of things like abdominal
991526 - trauma or episodes of reaching years after surgery and
991527 - even some patients where we have no explanation for why
991528 - they have this problem. So you certainly should
991529 - suspect it in the patients with complex reflux.
991531 - ..
991532 - 24. Regarding liberal use of the Collis gastroplasty, we
991533 - looked at our own experience. We found that 80% of
991534 - patients who have undergone a Collis gastroplasty have
991535 - persistent esophageal acid exposure after that
991536 - operation. I believe it is a good operation. But it
991537 - has to be done correctly.
991539 - ..
991540 - 25. You cannot get unlimited length with a Collis
991541 - gastroplasty. You can probably only get 2 cm of length
991542 - by creating the wrap around the neoesophagus. If you
991543 - do that, you will probably avoid the persistent
991544 - esophageal acid exposure. I really don't think we
991545 - should be looking at more liberal use of the Collis
991546 - because there is a considerable risk of continued acid
991547 - exposure.
991549 - ..
991550 - 26. Why are we seeing fewer misplaced wraps or malformed
991551 - wraps? I think there are probably 2 answers to that.
991552 - Number 1, people are learning how to do this operation.
991553 - They are being more aggressive about taking down the
991554 - short gastric vessels and those other principles that
991555 - we all come to understand. Number 2, I think fewer
991556 - surgeons are doing this operation. More of these
991557 - operations are now coming to referral centers and are
991558 - consolidating in centers of excellence, in part because
991559 - of the reports 3 and 4 years ago calling into question
991560 - the success of this operation.
991562 - ..
991563 - 27. Dr Richardson asked about the disaster patient. We do a
991564 - combined abdominal chest approach. We will leave the
991565 - patient without a wrap if we have to. We have not left
991566 - any wraps in the chest. We have had concerns about
991567 - reported incidents of perforation in those situations.
991568 - We have done some esophagectomies. If you have the
991569 - end-stage patient, you just take their esophagus out.
991571 - ..
991572 - 28. Dr Rege asked about the patient in whom you really
991573 - cannot find any anatomic basis for failure, what do we
991574 - do, counseling, sit on our hands? Every time we do a
991575 - redo, we take a wrap entirely apart. We have a few
991576 - patients that we have not rewrapped. I will tell you
991577 - hands down, for the patient who does not have an
991578 - objective basis for reoperation, you should not
991579 - reoperate. Those patients will inevitably do very
991580 - poorly.
991582 - ..
991583 - 7. Footnotes
991585 - ..
991586 - Reprints: C. Daniel Smith, MD, Department of Surgery, Emory
991587 - University School of Medicine, 1364 Clifton Road, NE
991588 - (H124), Atlanta, GA 30322. E-mail: ude.yrome@72timsc.
991590 - ..
991591 - 8. REFERENCES
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991699 -
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