Failed antireflux surgery - What have we learned from reoperations?

Hypothesis: Factors that lead to failures in antireflux procedures can be i dentified, and dealing with them at the initial operation may decrease the number of such failures. Design: Analysis of symptoms, 24-hour esophageal pH monitoring, manometry, upper gastrointestinal tract radiographs, and correlation with operative an atomic findings. Setting: University referral center. Patients: Forty-eight patients who previously underwent antireflux surgery (Nissen fundoplication, 29; Hill fundoplication, 7; Angelchik prosthesis, 1 ; multiple, 5; unknown, 6) and had symptoms of foregut disease. Main Outcome Measures: Determination of the cause of failure of previous op erations and identification of factors that may prevent recurrence. Results: Fourteen patients (29%) presented with symptoms of an incompetent cardia (heartburn and regurgitation), 15 patients (31%) presented with symp toms of defective esophageal emptying (dysphagia), 13 (27%) had symptoms of both, and 6 (13%) had other symptoms. All patients were initially treated medically and/or with dilation. A reoperation was performed in 31 patients (65%) whose symptoms persisted. Reoperation was completed laparoscopically in 28 patients (90%). At reoperation we identified 3 main types of failure: type I, patients in whom the gastroesophageal junction tvas herniated thro ugh the hiatus, either with the wrap (IA) or without it (IR). There were 13 patients (43%) classified as having type IA, and 5 patients (16%) classifi ed as having type IB. Type II failure involved a paraesophageal component r esulting from a redundant wrap in 5 patients (16%), and type iii involved a malformation (defective position or construction) of the wrap in 2 patient s (6%). The remainder had a failed Hill fundoplication (3 patients), a hern iated Angelchik prosthesis (1 patient), and normal postoperative anatomy (2 patients). Conclusions: Failure of the crural closure and malformation of the wrap are the main reasons for failure of antireflux procedures. Use of proper surgi cal techniques including meticulous closure of the crura and appropriate co nstruction and fixation of the wrap at the first operation will help preven t recurrence.