To the Editor.—The Nissen's fundoplication1 for complicated hiatal hernia and reflux esophagitis is an effective and relatively uncomplicated procedure. It adequately restores the gastroesophageal sphincter mechanism with respect to length and pressure, thus preventing reflux in the majority of patients. If the procedure is performed improperly, however, the fundoplication can slip down onto the body of the stomach, resulting in recurrent reflux and possible obstruction.
The "slipped" Nissen's fundoplication may be difficult to differentiate roentgenographically from herniation of the stomach through the plication, but the typical symptoms are those of recurrent hiatal hernia—reflux, pain, and dysphagia. Diagnosis is by means of upper gastrointestinal tract roentgenographic series and endoscopy. The hourglass appearance seen on barium swallow roentgenogram (Figure) is classic but can occur intermittently.
Operative repair usually involves replacing the plication in its appropriate position above the gastroesophageal junction and securing it with stout seromuscular sutures through the gastroesophageal