The failure of antireflux procedures to relieve symptoms may be secondary to a variety of causes and usually occurs in the first 2 years after the initial procedure.

Immediate/early Failure

A relatively uncommon cause is misdiagnosis of the original problem with an incomplete or misinterpreted primary preoperative evaluation. Immediate failures may occur, that is, obvious problems of severe dysphagia from too tight a wrap or a severe underlying motor disorder that was underestimated. Other immediate problems may occur due to failure to completely reduce the hernia at the initial operation with immediate symptoms. Early postoperative retching can occur with immediate re-herniation. Alternatively, the wrap may have been constructed appropriately, with good initial results but disruption or transdiaphragmatic herniation may occur in a delayed fashion. Some of these may be due to a sentinel event, such as heavy lifting, in which the patient notes the immediate return of symptoms.

Late Causes of Failure

Hunter and associates (1999)[11] examined the results of laparoscopic fundoplication in 758 patients and found that the mechanism of failure was transdiaphragmatic herniation in 84%, a slipped fundoplication in 32%, and a twisted fundoplication in 30%. In an update of the same series, it was again reported that the majority of failures were secondary to a transdiaphragmatic herniation of the wrap .[12] A series by Hinder and colleagues[13] reported the results of laparoscopic reoperation in 46 patients, with the two most common causes of failure being breakdown of the fundoplication in 35% and breakdown of the crural repair in 22%. A slipped wrap (15%) and a wrap that was too loose (8%) or too tight (8%) were less frequently observed in this series. Also in this series, nearly 70% of patients who required reoperation had recurrent symptoms within 2 years of their original surgery, suggesting that operative techniques play an important contributing role in the failure of antireflux procedures.

Other complications, such as inadvertent vagal injuries, can lead to significant bloating, delayed gastric emptying, and even recurrent gastroesophageal reflux. In addition, failure to identify a shortened esophagus, either preoperatively or intraoperatively, and the failure to adequately dissect and reduce a hiatal hernia can also lead to herniation of the wrap and symptoms.

Herniation and Disruption of Wrap

Herniation of the fundoplication usually results from disruption of the crural repair or failure to perform the initial wrap over a tension-free segment of intra-abdominal esophagus. There must be at least 2 to 3 cm of tension-free intra-abdominal esophagus below the hiatus, and the gastroesophageal junction must be clearly identified. The most consistent way to definitively define the GEJ is dissection of the gastroesophageal fat pad to allow direct vision of the precise location of the end of striated muscle fibers and the beginning of the serosa of the stomach. In closing the crus, the peritoneum overlying the muscle is preserved, with the peritoneum acting as a pledget for the crural closure. Failure of the crural repair can result from excessive tension during the primary suture placement or inadequate tissue in which to place the crural sutures.

A large esophageal hiatus occasionally requires a relaxing incision in the diaphragm and/or mesh repair. If during a difficult dissection, the crural fibers are clearly visible with no overlying peritoneum, careful apposition with pledgeted sutures and or mesh will likely be necessary. Although many authors have advocated the liberal use of mesh, there is randomized controlled data that suggests mesh does not improve rate of recurrence[14]. In general, if a tension-free repair of healthy crural tissue is not possible, one should consider some form of buttress or mesh.

Slipped Fundoplication

A slipped Nissen fundoplication occurs when part of the stomach lies both above and below the wrap (Figure 1). This defect may arise from the stomach slipping through the fundoplication or incorrect positioning of the wrap around the stomach at the time of the original surgery.[13] Often a chronically tubularized cardia of the stomach will resemble the esophagus and be wrapped during the initial procedure, emphasizing the importance of clearly identifying the gastro-esophageal junction. Ruling out the presence of esophageal shortening and ensuring a tension-free wrap around the intra-abdominal portion of the esophagus are essential in minimizing the occurrence of this complication.

Figure 1 

Retroflexed endoscopic view of the appearance of a slipped Nissen fundoplication with the wrap and fundus herniated across the diaphragm.

Fundopliction – Too Loose/too Tight

A fundoplication that is too tight may lead to dysphagia, and a wrap that is too loose may not be therapeutic.[15] Preoperative manometric findings, the patient’s body habitus, and intraoperative findings after mobilization of the stomach and distal esophagus must be carefully considered in tailoring the fundoplication. A laparoscopic Nissen fundoplication is generally performed around a Maloney bougie ranging in size from 52 to 56 Fr for the small to average sized (70-kg) patient. In larger patients, the fundoplication is generally wrapped around a 54- to 56-Fr bougie. A “shoe-shine” maneuver is performed at the time of fundoplication to allow careful assessment of the length and to ensure that the fundus is not under tension and slides freely.

A recent randomized study of “bougie versus no bougie” use during laparoscopic Nissen fundoplication showed that the bougie group had a lower incidence of clinically significant dysphagia postoperatively.[16] In the patient with impaired esophageal motility, our preference is a floppy Nissen wrap over a slightly larger bougie. Some reports have shown good results in patients with impaired esophageal motility using a partial fundoplication such as a Toupet or a Belsey repair.

Vagal Injury

Familiarity with the anatomy and meticulous dissection around the hiatus will minimize the risk of intraoperative injury to the vagus nerves. Injury to even one of the vagus nerves can lead to the exacerbation of usually mild postoperative bloating, often managed with careful dietary counseling and medications such as simethicone. Injury to both vagi frequently results in markedly delayed gastric emptying and dumping symptoms.[17]

If an injury to both vagus nerves is identified intraoperatively or is suspected preoperatively based on an abnormal gastric emptying test, the addition of a gastric emptying procedure such as a laparoscopic pyloroplasty is considered. In our experience, if this is seen during a reoperation we would generally make a floppier than usual Nissen repair or consider a partial wrap to minimize the inevitable bloating that will be seen. In general, we delay the decision to perform pyloroplasty until a period of “watch and wait” is given.

Esophageal Shortening

Although controversial, it is hypothesized that long-standing reflux leads to circumferential esophageal scarring and, in more severe cases, varying degrees of longitudinal scarring and esophageal shortening. Esophageal shortening is suspected in the presence of peptic stricture, Schatzki’s ring, Barrett’s esophagus, and moderate to giant hiatal hernias.

Initially, a barium esophagogram may be helpful in detecting patients who have esophageal shortening and in some cases this is very obvious (Figure 2). In addition, a shortened esophagus can be detected preoperatively by a manometric intrathoracic location of the lower esophageal sphincter. Manometry may also reveal a shortened intersphincteric distance between the upper and lower sphincters.[18] A careful intraoperative evaluation with dissection of the gastroesophageal fat pad is essential in identifying the true gastroesophageal junction and excluding esophageal shortening. Intraoperative endoscopy may also aid in recognition with borderline cases

Figure 2 

Barium esophagogram demonstrating a shortened esophagus.

Intraoperative Identification of Esophagheal Shortening

Several aspects of antireflux surgery and, in particular, laparoscopic antireflux surgery may contribute to the failure to recognize a shortened esophagus. The placement of a rigid bougie can place downward tension on the gastroesophageal junction, leading to several centimeters of intra-abdominal length that will subsequently retract with removal of the bougie. With laparoscopic procedures, pneumoperitoneum can elevate the diaphragm, again giving the impression of a longer segment of intra-abdominal esophagus. In addition, traction on the gastroesophageal junction (with, for example, a Penrose drain) can also lead to subsequent herniation of the wrap above the diaphragm.

Adequate laparoscopic mobilization of the mediastinal esophagus is critical in constructing a tension-free, intra-abdominal fundoplication. If esophageal shortening is identified and adequate intra-abdominal esophageal length cannot be obtained, a Collis gastroplasty may minimize the incidence of subsequent wrap herniation and ultimate failure. Excellent short-term results have been reported using several minimally invasive approaches to a Collis gastroplasty.

Pseudoachalasia

Pseudoachalasia or secondary achalasia is being increasingly recognized as an entity for late-onset dysphagia after antireflux surgery. In many of these patients dysphagia develops after apparent technically successful antireflux surgery. Stylopoulos and colleagues reported a series of 7 patients and defined secondary achalasia by the following criteria[19]:

1. Preoperative manometry demonstrating normal peristalsis and lower esophageal sphincter relaxation
2. Lack of postoperative peristalsis
3. No mucosal lesions seen on endoscopy
4. Dysphagia refractory to dilation

Pseudoachalasia tended to occur in older patients and was characterized by delayed onset of symptoms. These investigators noted improvement with botulinum toxin injection in 2 patients and myotomy in 1 patient. Esophageal manometry is critical to this diagnosis, and it is important to recognize the development of pseudoachalasia or secondary achalasia as the cause of symptoms.

Common Symptoms Following Antireflux Surgery

Transient symptoms of dysphagia, bloating, and dietary intolerance are not infrequent in the immediate 4- to 6-week period after the initial operation and usually resolve with conservative management. Some patients experience a short course of diarrhea, which is frequently related to gas bloat and often settles with a slower progression of diet and the addition of simethicone. Increased flatus and the inability to vomit or belch are other common complaints, and, again, medications such as simethicone may help symptoms. If diarrhea or gas bloating persists, injury to the vagal nerves is considered; most of these problems can be managed conservatively with an anti-dumping dietary regimen and a significant “tincture of time.” In some cases, a gastric emptying procedure such as a pyloroplasty or pyloromyotomy may be of benefit. For dysphagia, we generally reserve dilation for patients whose symptoms persist beyond 2 to 3 months. Persistent dysphagia despite these measures requires a thorough evaluation and consideration for reoperation.

Early Postoperative Symptoms

A complaint of foamy salivation or the inability to tolerate liquids immediately postoperatively may be a result of a technical error or a failure to recognize a severe esophageal motility disorder. The postoperative barium esophagogram usually confirms a very tight wrap that is unlikely to improve with time and warrants consideration for early reoperation.

Recurrent Preoperative Symptoms Following Antireflux Surgery

The patient with persistent symptoms after an antireflux procedure must have an exhaustive clinical evaluation. The principal symptoms that lead to consultation and potential reoperative surgery are recalcitrant heartburn and dysphagia. Gas bloat and gastrointestinal symptoms are seldom an indication for redo surgery. A careful review of the patient’s initial symptoms, previous response to medical therapy, and prior test results can help in recognizing the presence of an esophageal motility disorder (e.g., achalasia) or undiagnosed gastrointestinal disorders (e.g., chronic cholecystitis). This may require the assistance of an experienced and trusted gastroenterologist. The previous workup and the original indication for surgery is carefully reviewed. A careful review of the operative notes and discussion with the original surgeon may provide detail regarding the dissection of the esophagus, short gastric vessels, and the gastroesophageal fat pad. In addition, the positioning and status of the vagal nerves, bougie size, and type of crural repair may assist in recognizing subtle technical errors.

Basic Workup - Recurrent Symptoms

At a minimum, our approach to the patient with recurrent symptoms includes a barium videoesophagogram, chest radiograph, upper gastrointestinal endoscopy, esophageal motility testing, 24-hour pH testing, and a nuclear medicine gastric emptying study. The results of these tests are invaluable in determining the cause and possible solution to recurrent or new symptoms after an unsatisfactory result from antireflux surgery. In the setting of an obvious bilateral vagal injury, with marked delay in gastric emptying, our experience has been that reoperative antireflux surgery has a higher failure rate. One may need to consider other options such as Roux-en-Y conversion or esophagectomy.

Barium Esophagography

Several radiologic patterns identified on the barium esophagogram can assist the surgeon in determining the cause of a failed wrap (Figure 3):

• Type I abnormality represents a near complete or complete disruption of the wrap with recurrence of the hiatal hernia.
• Type II defect occurs from slippage of a portion of the stomach above the diaphragm, usually caused by incorrect positioning of the fundoplication around the upper stomach rather than esophagus. A classic “hourglass” appearance may be observed.
• Type III defect, commonly referred to as a slipped Nissen, is seen when part of the stomach lies both above and below the wrap. This defect may arise as a result of slippage of the stomach through the fundoplication or incorrect positioning of the wrap around the stomach at the time of the original surgery.
• Type IV abnormality is seen when the entire fundoplication herniates into the chest, usually as a result of a disrupted crural repair.

Figure 3 

Four types of failed wraps.

Upper Gastrointestinal Endoscopy

Upper gastrointestinal endoscopy is performed to assess for esophagitis, stricture, gastritis, ulceration, or tumor and to evaluate the position and integrity of the wrap. This is ideally performed before surgery. An intact fundoplication has the typical “stack of coins” appearance on a retroflexed view with the endoscope (Figure 4). Interpretation of the endoscopic findings to determine the mechanism of the failure requires experience and knowledge. For example, the presence of gastric mucosa above the wrap suggests the possibility of a slipped Nissen fundoplication. Alternatively, a widely patent gastroesophageal junction viewed on retroflexion of the endoscope positioned in the stomach suggests that the cause of recurrent symptoms may be attributed to a loose or disrupted wrap. In addition, other abnormalities such as twisted fundoplication or a two-compartment stomach may be noted (Figures 5 and 6). Identifying the squamocolumnar junction and its relation to the diaphragmatic crura can help make an assessment of esophageal length.

Figure 4 

A to C, Endoscopic view of intact fundoplication with typical stack of coins appearance of wrap on retroflexed view.

Figure 5 

Endoscopic view of a twisted fundoplication.

Figure 6 

Endoscopic view of a two-compartment stomach.

Esophageal Manometry

Esophageal manometry is essential in the evaluation of a patient with a failed antireflux procedure. The initial manometry may have been improperly performed or interpreted, and subsequent manometry may provide valuable information regarding esophageal motility. Excluding the presence of poor esophageal peristalsis or other esophageal motility abnormalities, such as diffuse esophageal spasm or achalasia, is crucial before proceeding to operation.

In addition, manometry allows for an assessment of the lower esophageal sphincter, with a low-pressure reading indicating a fundoplication may have been disrupted or is too loose and a high-pressure reading suggesting a fundoplication that is too tight. The distance from the upper to the lower esophageal sphincter can also be measured and may indicate esophageal shortening.

24-Hour Esophageal Ph Studies

Twenty-four-hour esophageal pH studies are also necessary in evaluating patients with recurrent symptoms of GERD after surgery.[20] In addition to demonstrating recurrent episodes of acid reflux, the presence of an excessively alkaline environment suggests the possibility of duodenogastroesophageal reflux.[21]

After the induction of anesthesia, esophagogastroduodenoscopy is performed. This allows for assessment of Barrett’s esophagus, stricture, the location and integrity of the previous wrap, presence of a twisted fundoplication, and evaluation of esophageal length. The scope is often left in the esophagus for intraoperative evaluation. An arterial line for continuous blood pressure monitoring assists in managing insufflation pressures and monitoring for the development of a tension pneumothorax. This occurs more frequently than in first-time cases, especially when reoperative surgery involves a significant thoracic dissection. We prefer the patient in the supine position, with steep reverse-Trendelenburg, and with the surgeon to the right of the patient.

Port Placement

Initial port placement is performed with direct peritoneal visualization. A key technical point is that the first laparoscopic port inserted is placed away from any previous incisions. Regardless of location, an open technique is used for placement of the first port. Once a laparoscopic view of the peritoneal cavity is obtained, adhesiolysis is performed in the upper abdomen to allow usual port placement used for laparoscopic antireflux surgery. If dense adhesions are encountered, we generally add a more inferior and lateral port to allow better visualization and assist with the lysis of adhesions. After complete lysis of adhesions, we convert to our standard five (two 10-mm and three 5-mm) access ports (Figure 7).

Figure 7 

Standard laparoscopic port placement for initial and reoperative antireflux surgery. (COPYRIGHT JENNIFER DALLAL, JAMES D. LUKETICH, MD.)

Typically a 10-mm, 30-degree laparoscope is used in reoperative surgery because it provides a wider and more precise view of the operative field. Lower insufflation pressures in the 8- to 10-mm Hg range are often sufficient for the dissection around the hiatus and to minimize the effects of a prolonged pneumoperitoneum during laparoscopic reoperation.

Initial Mobilization

After a careful examination of the peritoneal cavity, mobilization of the esophagogastric junction is performed. The density of adhesions around the hiatus and wrap are unpredictable, and often the most severe adhesions are located between the stomach, distal esophagus, and liver. This can make mobilization of the stomach and distal esophagus from the liver and crus extremely difficult. Care is taken during this part of the dissection to avoid perforation of the stomach and esophagus. Careful and meticulous dissection with autosonic shears (U.S. Surgical, Norwalk, CT) or harmonic scalpel (Ethicon, Cincinnati, OH) is helpful and minimizes the risk of injury to surrounding structures and provides a relatively bloodless field. The repair of multiple gastric perforations can lead to difficulty in creating a new fundoplication by changing the anatomy and pliability of the stomach. Every effort is made to identify and protect the vagus nerves. If a patient gives a history suggestive of delayed gastric emptying and has an abnormal nuclear gastric emptying study, a pyloroplasty may be included in the procedure.

If hypotension or high ventilatory pressures are detected during the dissection of the hiatus, a pneumothorax is suspected and treated by placement of a chest tube. We prefer a 12-Fr pigtail catheter in the affected hemithorax.

Full mobilization of the distal esophagus, the fundus of the stomach, and the gastroesophageal fat pad and identification of the crus are essential in reoperative antireflux surgery. Early identification and complete takedown of the wrap as well as removal of crural sutures will facilitate complete mobilization. A complete takedown of the previous wrap and re-establishing normal anatomy is an essential component of the operation. This may require further division of the short gastric vessels and mobilization of the esophageal fat pad to identify the true gastroesophageal junction if this has not been performed previously.

Collis Gastroplasty

The recognition of a shortened esophagus may require the addition of a Collis gastroplasty to the antireflux repair. The requirement for a Collis gastroplasty may be suspected on the basis of manometric, radiologic, and/or endoscopic findings. However, the final decision is made intraoperatively, after takedown of the previous repair and complete mobilization of the esophagus into the mediastinum. If less than 2-3 cm of tension-free intra-abdominal esophagus is present, a Collis gastroplasty should be performed.[22] A Maloney esophageal bougie (typically 56 Fr) is placed by the surgical team across the gastroesophageal junction along the lesser curve. A wedge gastroplasty is then performed. With the bougie in place, the fundus of the stomach is grasped with one grasper at the Angle of His and a grasper placed further down on the greater curve and the fundus rotated to the right upper quadrant. An Endo GIA stapler is introduced into the abdomen, with the first row of stapler firings coming across the superior portion of the fundus up to the bougie (Figure 8). The next row of staples comes along the bougie to amputate the wedge of fundus and create the segment of neo-esophagus. To accomplish this, the portion of fundus to be removed is held up with two graspers, while the residual fundus rotates back to the right. A stapler is then fired along the length of the bougie, removing the wedge of stomach (Figure 9, 10).

Figure 8

Two graspers are used to rotate the Angle of His and the greater curve to the right upper quadrant. An Endo GIA stapler is then used along the superior portion of the fundus.

Figure 9

The Endo GIA stapler is then used again to amputate this piece of fundus along site the bougie.

Figure 10

Completed wedge Collis Gastroplasty

Redo Fundoplication

A floppy 2- to 3-cm 360-degree Nissen wrap is performed over a Bougie (or neo-esophagus if a Collis gastroplasty is included) (Figure 11). The crura are approximated posterior to the wrap (Figure 12). If the crura cannot be reapproximated in a tension-free manner, mesh is used to close the crural defect. Occasionally, a prosthetic patch is required to perform an adequate crural reapproximation. Our current mesh of choice is Surgisis ES (Cook Surgical, Bloomington, IN).

Figure 11 

Suturing of 360-degree wrap around Collis segment. (COPYRIGHT JENNIFER DALLAL, JAMES D. LUKETICH, MD.)

Figure 12 

Completed crural repair and Collis-Nissen fundoplication. (COPYRIGHT JENNIFER DALLAL, JAMES D. LUKETICH, MD.)

A myotomy and partial fundoplication (Dor or Toupet) is considered in patients with secondary achalasia or pseudoachalasia. A Roux-en-Y (RNY) gastric bypass is contemplated in morbidly obese patients or patients who have undergone multiple antireflux operations The RNYanatomy by definition seperates the acid producing parietal cells of the antrum thereby preventing esophageal reflux of acid. A small gastric pouch (or esophagojejunal anastomosis) is necessary to ensure no retention of parietal cells. It must be emphasized that the wrap is completely taken down before performing the Roux-en-Y gastrojejunostomy.

Postoperative Care

After the procedure a nasogastric tube is placed under direct vision. In the recovery room, a baseline hematocrit is obtained and a chest radiograph is performed to rule out an occult pneumothorax. A barium swallow is typically performed on the first or second postoperative day. If no extravasation of contrast medium is observed on barium swallow, and in the absence of gastric ileus or abdominal distention, the nasogastric tube is subsequently removed and the patient is started on a clear liquid diet. In general, the patient remains on a soft diet for 1 to 2 weeks after surgery.