Management of the failed reflux operation is emerging as an important challenge in modern surgical foregut practice. Over the last decade and a half, the number of patients referred for antireflux surgery has increased eightfold. Approximately 70,000 operations are performed annually in the United States.¹ The increased use of minimally invasive techniques to treat gastroesophageal reflux disease (GERD) has resulted from the lower perceived morbidity associated with laparoscopy in comparison with the open approach.

Most patients who undergo laparoscopic antireflux surgery experience good long-term outcome. Specialty centers report 90% to 95% “sustained benefit” after initial surgery, although not all centers see their own complications.^2,3 The results published by the broader surgical community are less favorable.^3,4 This finding is similar for laparoscopic and open surgery. However, the results are subjective and depend on the definition of failure and the experience of the surgeon.^5–9

The failure of antireflux surgery may occur early or late. The etiology of the failure is associated with and is sometimes revealed by the timing of symptoms. Early failures can be attributed to poor patient selection and technical error.⁹ For example, the misdiagnosis of an unrecognized primary esophageal motility disorder (PEMD) may lead to improper choice of surgical procedure, which dooms the procedure to fail.^10,11 Late failures may be secondary to the progression of underlying disease or attributed to the length of the procedure.¹²

After several decades of experience, multiple reports of transient increases in failed antireflux procedures have ascribed these failures to the initial learning-curve effect,^13–15 modifications of surgical technique during the initial transition to laparoscopic approach,¹⁶ and relaxation of patient selection criteria. With growing experience in the thoracic community, however, these sorts of failures are expected to diminish.

Despite good surgical results after initial operation, some patients present with recurrent symptoms or mechanical failure. Most of these patients can be managed medically with good results. However, 4% to 10% of patients become or remain symptomatic with a poor quality of life and seek additional surgical therapy.^2,10,17–21 Success rates for reoperations range between 50% and 89%.⁶ Second and third reoperations traditionally are associated with lower success rates, decreasing as much as 20% with each subsequent operation.²² The technical difficulty of reoperation has led some surgeons to advocate an open approach.²³ Evidence supporting the safety and efficacy of laparoscopic reoperation, however, is increasing.^1,2,6,24 In our experience, the laparoscopic approach to reoperation is feasible in over 95% of patients regardless of the approach used for the primary or previous surgeries (e.g., open or laparoscopic, thoracic, or abdominal).

Determining the cause is the difficult aspect of reevaluating patients with recurrent reflux. First, one must establish whether the patient’s reflux or procedure-related symptoms are from surgical failure or attributable to some other etiology. In this regard, the diagnosis always should be reexamined to rule out previously undiagnosed or misdiagnosed conditions such as PEMD.

A thorough history is essential to distinguishing the patient’s current symptoms from symptoms experienced preoperatively. The relevant symptoms include heartburn, dysphagia (e.g., generalized liquids or solids), postprandial pain, and respiratory symptoms, in particular, recurrent pneumonia and aspiration. If the patient has chest pain, it should be evaluated to discern whether it is secondary to reflux or to some other cause of typical or atypical chest pain (Table 43-1). In our practice, several patients referred for antireflux surgery were found on preoperative workup to have postprandial angina. Another common cause of chest pain is dysphagia that often can be fixed with endoscopic dilatation.

It is essential to understand the mechanics of the patient’s previous antireflux procedure by obtaining the operative report and previous diagnostic studies. Understanding the neoanatomy and expected physiologic change is vital to interpreting new diagnostic examinations and procedures. Possible reasons for postoperative reflux include failure of surgical technique or incorrect choice of surgical procedure for the patient’s initial problem. The failure in surgical technique may take many forms: obstruction (e.g., hiatus, wrap too tight, wrap too long, or wrap poorly placed), herniation (e.g., hiatus not closed adequately or short esophagus), dehiscence (e.g., poor stitch placement, knot tie, and depth), and poor gastric emptying secondary to vagal injury. Consequently, the surgeon performing the evaluation should be familiar not only with the technical details of the patient’s original operation but also with all of the procedure-related pitfalls and late complications.

Hinder et al.⁵ described four failure patterns after open fundoplication: the slipped or misplaced fundoplication, the disrupted fundoplication, the herniated fundoplication, and the excessively tight or long fundoplication. Two additional failure patterns have emerged in the laparoscopic era: the twisted fundoplication and the two-compartment stomach⁹ (Fig. 43-1). The incidence of wrap failure linked to cause is variable. In our opinion, it is usually related to surgical technique and largely preventable. For example, routine hiatal repair at initial operation has been shown to reduce the incidence of recurrent herniation by 80%, and this practice has become standard of care.²

The evaluation of patients with recurrent reflux at our institution includes the four standard studies used for GERD: 24-hour esophageal pH probe study, manometry, esophagogastroduodenoscopy (EGD), and esophagram or cine. In addition, for patients with recurrent reflux, we routinely obtain esophageal and gastric emptying studies (i.e., nuclear scintigraphy). If nonacid reflux is suspected, an impedance study is also obtained.

The aim of the evaluation is to differentiate the anatomic versus physiologic cause of the patient’s symptoms. Tailoring an effective surgical solution depends on this evaluation. Problems to look for include the presence of a previously undiagnosed PEMD, other esophageal anomaly, postoperative obstruction at the gastroesophageal junction (GEJ), or a primary delayed gastric emptying disorder. A large series of 104 patients demonstrated that a thorough preoperative evaluation can predict the mechanism of postfundoplication failure found at reoperation in 78% of patients.¹ Mechanisms of postfundoplication failure in this cohort are summarized in Table 43-2.