BACKGROUND: Acute wrap failure post fundoplication is a rare but recognized complication and can be due to patient factors, disease factors and surgical factors. Herniation of the stomach into the thorax can mimic a pneumothorax clinically and radiologically and thus lead to bad outcomes for patients.
METHODS: We report the case of a 20-year-old male who presented to the emergency department with progressively worsening upper abdominal pain, nausea and vomiting followed by acute onset dyspnoea, six days post a laparoscopic repair of a small hiatus hernia and a Nissen fundoplication. His chest x-ray was consistent with that of a left sided pneumothorax and was therefore, appropriately resuscitated and treated with an intercostal catheter (ICC). A subsequent CT scan of the chest revealed a left gastrothorax. The patient was taken to theatre for the surgical reduction of the paraoesophageal hernia.
CONCLUSIONS: Patients with a recent history of anti-reflux surgery, who present with a pneumothorax and respiratory distress or a tension pneumothorax should always be treated with an ICC. However, follow up imaging with a CT scan is essential to confirm diagnosis. Good control of post- operative nausea and vomiting is essential in avoiding wrap failure and ensuing complications.
CONCLUSIONS: A high index of suspicion for a gastrothorax mimicking a pneumothorax is important in the setting of recent anti-reflux surgery.

BACKGROUND: A minority of patients undergoing surgery for refractory gastroesophageal reflux disease (GORD) will require revision antireflux surgery (\"redo-ARS\") for persistent symptoms or complications. Although a repeat minimally invasive procedure for revision may be technically challenging due to post-operative changes, studies are beginning to show favourable data for the laparoscopic approach.
METHODS: From a single institution 41 consecutive cases of laparoscopic redo-ARS performed by the same surgeon were classified by mode of presentation to analyse their intra-operative findings, management and post-operative outcomes. Cases were classified as either early, emergency or late.
RESULTS: There were 12 early, 4 emergency and 25 late redo-ARS cases. Complete resolution of symptoms, using the criteria of less than weekly symptoms and off all anti-reflux medications, were acquired in 6 (50%), 2 (50%) and 16 (64%) patients within the early, emergency and late groups respectively. Overall morbidity following revision was 7.3% with no mortality. There were no open conversions.
CONCLUSIONS: Although fewer patients will achieve complete resolution of symptoms as compared with outcomes following primary ARS, laparoscopic revision of ARS is a safe and effective approach for the revision of anti-reflux surgery in the early, emergency and elective settings.

Laparoscopic anti-reflux surgery is conventionally performed using two 10/12 mm ports. While laparoscopic procedures reduce post-operative pain, the use of larger ports invariably increases discomfort and affects cosmesis. We describe a new all 5 mm ports technique for laparoscopic anti-reflux surgery and present a review of our initial experience with this approach.
All patients undergoing laparoscopic fundoplication over a 35 month period from February 2013 under the care of a single surgeon were included. A Lind laparoscopic fundoplication was performed using an all 5 mm port technique. Data was recorded prospectively on patient demographics, operating surgeon, surgical time, date of discharge, readmissions, complications, need for re-intervention, and reasons for admission.
Two hundred and five consecutive patients underwent laparoscopic fundoplication over the study period. The all 5 mm port technique was used in all cases, with conversion to a 12 mm port only once (0.49%). Median operating time was 52 min 185 (90.2%) patients were discharged as day cases. Increasing ASA grade and the presence of a hiatus hernia were associated with the need for overnight stay with admission required in 33% of patients with ASA 3, compared to 4% with ASA 1 (p = 0.001), and 29% of those with a hiatus hernia vs. 5% without (p < 0.001). No port-related complications occurred, and no patients developed recurrence of reflux symptoms. A single patient required mesh repair of a large hiatus hernia.
The all 5 mm ports approach to laparoscopic anti-reflux surgery is a safe, efficient, and cost-effective technique which facilitates same day discharge and minimises port related complications. National commissioning guidelines in the UK should target quality improvements in anti-reflux surgery based around day-case management. This would improve the service for these patients and culminate in cost savings for the NHS.