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Analysis of the Causes of Failed Antireflux Surgery and the Principles of Treatment A Review

Marco G. Patti, MD1; Marco E. Allaix, MD2; P. Marco Fisichella, MD, MBA3,4
[+] Author Affiliations
1Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
2Department of Surgical Sciences, University of Torino, Torino, Italy
3Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
4Boston VA Healthcare System, Boston, Massachusetts
JAMA Surg. 2015;150(6):585-590. doi:10.1001/jamasurg.2014.3859.
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Importance  Although the diagnostic evaluation and technical elements for a successful laparoscopic fundoplication have been clearly identified, 10% to 20% of patients will eventually experience recurrence of their symptoms. The management of patients who fail antireflux surgery is complex and not well codified.

Objective  To provide an evidence- and experience-based analysis of the causes of failed antireflux surgery and to underscore the principles of treatment.

Evidence Review  PubMed was searched for articles published between 1980 and 2014. The search terms included were the following: heartburn, regurgitation, dysphagia, gastroesophageal reflux disease, cough, aspiration, laryngitis, GERD, GORD, endoscopy, manometry, pH monitoring, proton pump inhibitors, and Nissen fundoplication.

Findings  Before planning therapy, a careful workup is necessary to determine whether the symptoms are due to recurrent reflux and to understand what caused the recurrence. Subsequently, therapy needs to be individualized based on the symptoms and on the findings of the workup. In some patients, a nonesophageal cause will be identified. Among patients with recurrent reflux, some will do well with acid-reducing medications and others will need another operation.

Conclusions and Relevance  Laparoscopic antireflux surgery is a very effective and long-lasting treatment for gastroesophageal reflux disease. Its success is based on a careful preoperative evaluation and on the performance of a fundoplication that respects the key technical elements. Patients who are still symptomatic postoperatively must be thoroughly evaluated to identify the cause of failure, and treatment must be individualized.

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Figure 1.
Type IB Recurrence

A, Lateral view of the barium swallow of a patient who presented with recurrent heartburn and regurgitation 5 years after a laparoscopic Nissen fundoplication. B, The wrap is located below the diaphragm, while the gastroesophageal junction is located above it.

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Figure 2.
Type II Recurrence

A, Lateral view of the barium swallow of a patient who presented with recurrent heartburn and regurgitation 3 years after a laparoscopic Nissen fundoplication. B, The redundant stomach is located above the wrap and it is herniated above the diaphragm.

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Figure 3.
Type III Recurrence

A, Anterior view of the barium swallow of a patient who presented with no heartburn and regurgitation but with new-onset dysphagia 2 months after a laparoscopic Nissen fundoplication. B, The body rather than the fundus of the stomach was used to construct the wrap and the short gastric vessels were not divided during the initial operation. Any attempts to treat dysphagia by pneumatic dilatations were ineffective.

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Figure 4.
Treatment Algorithm for Patients With Recurrent Symptoms After Laparoscopic Antireflux Surgery
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