Fundoplication surgery generally provides excellent short-term relief from the classic symptoms of reflux, including typical heartburn or acid burning in the chest, epigastric discomfort, and regurgitation. However, many patients may experience a return of these symptoms to some degree over the long term. Existing literature suggests that about 10–40% of patients will report at least mild reflux symptoms at 5-year follow-up [2, 16], Continued use of acid suppression medications after surgery is also common. One review of over 2400 patients in the United States VA healthcare system found that more than 40% were prescribed PPI therapy at least once 6 months or more after anti-reflux surgery, and more than 30% were prescribed an H2 blocker [12].

However, it is not always clear whether continued acid reflux is truly the cause of persistent or recurrent symptoms after surgery. Studies have found that only 38% of patients reporting subjective symptoms have objective evidence of reflux found on endoscopy or barium swallow [1], and this number falls to 23% when routine pH testing is performed [17]. Both functional and psychiatric co-morbidities may be the underlying cause when objective reflux testing does not explain the persistent symptoms [18].

Predicting which patients will suffer a recurrence of their reflux symptoms after surgery is difficult and studies looking for risk factors have produced mixed results. A 2009 systematic review in the American Journal of Gastroenterology looked at 63 observational studies (53 cohort, 10 case-control) and did not find consistent evidence for any individual risk factors for symptom occurrence after fundoplication. This included age, sex, BMI, and pre-operative response to acid suppression. Interestingly, studies looking at stress and psychological co-morbidities generally supported an association with poor symptomatic outcome after fundoplication, but the authors warn that many of these studies had significant methodological limitations [19]. Some other factors on pre-operative testing previously associated with poor symptomatic outcome include lack of objective signs of reflux on pre-operative assessment, negative symptom-association, and spastic or hypermotility patterns on esophageal manometry [20].

Contrary to popular belief, the rate of persistent reflux symptoms reported after surgery is no different in patients receiving laparoscopic full (Nissen) fundoplication versus a partial (Toupet) fundoplication. This was shown in a 2015 meta-analysis that looked at 13 randomized controlled trials involving over 1500 patients [9].

In contrast, laparoscopic posterior (Nissen) fundoplication has been shown to provide superior control of reflux symptoms when compared to laparoscopic anterior fundoplication [10]. However, as previously mentioned, posterior fundoplication also produces a higher rate of post-operative dysphagia.

In all patients who report subjective reflux symptoms after fundoplication, it is important to first determine whether the surgical anatomy remains intact. Barium esophagram provides a quick, non-invasive way of assessing the post-operative anatomy in these cases. A normal, intact fundoplication characteristically appears as smoothly narrowed distal esophagus surrounded by a large fundal filling defect that correlates with the wrap itself (Fig. 8.3) [21]. In addition, in patients with persistent gastroesophageal reflux, the esophagram may sometimes demonstrate refluxing of contrast up the esophagus above the level of the LES. However, the lack of reflux events visualized on esophagram does not exclude persistent reflux as a cause of symptoms.

Free reflux seen on barium esophagram may indicate an incompetent repair, breakdown or alteration of the fundoplication wrap. In addition, an abnormal appearance or loss of the fundal defect may indicate wrap disruption, and the appearance of a new or recurrent hiatal hernia sac may suggest slippage of the proximal stomach or wrap itself above the diaphragm [21]. Images from an abnormal barium esophagram following gastric slippage through a fundoplication leading to hiatal hernia can be seen in Fig. 8.4.

In cases where a barium swallow is suggestive of gastric herniation or disruption of the repair, upper endoscopy should be done to further assess the abnormality. As seen in Fig. 8.5a, b, extension of the rugal folds of the stomach above the narrowing of the repair can indicate formation of a hiatal hernia. It is important to have a radiologist, surgeon and/or gastroenterologist experienced in evaluating post-surgical gastric anatomy take part in this work-up, as their impression may factor heavily into any decision regarding revision surgery.

For patients with reflux-type symptoms after fundoplication with a normal post-surgical anatomy seen on barium swallow and endoscopy without obvious signs of reflux, repeat objective reflux testing (ambulatory pH or combined pH-impedance study) can be used to assess whether their symptoms are actually attributable to abnormal reflux. Positive reflux testing in this setting may indicate that the wrap is not sufficient in providing an adequate barrier to reflux between the stomach and esophagus, despite appropriate positioning. This may be due to looseness of the wrap or other factors resulting in a high trans-diaphragmatic pressure gradient, such as obesity, delayed gastric emptying, or pulmonary diseases. Esophageal manometry should also be performed to help assess the pressure at the gastroesophageal junction and identify esophageal dysmotility, such as frequent ineffective swallows or absent contractility that may predispose to increased or worsened reflux.

The first-line approach to patients with persistent or recurrent reflux symptoms post-fundoplication is empiric medical therapy, similar to that for the general population, utilizing proton pump inhibitors (PPI) and H2-receptor blockers. As of yet, there have not been any specific studies or data to guide either PPI or H2 blocker dosing in this setting. For this reason, we recommend an initial trial of a daily PPI at low dose for 8 weeks as a first step, either in the morning or in the evening, regardless of the patient’s pre-operative acid suppression requirement. Importantly, PPIs must be taken 15–30 min prior to eating to allow maximal efficacy. This allows sufficient time for medication absorption, where it works at the cellular level to block the gastric acid production that is stimulated by eating.

If symptoms do not improve on low-dose PPI, escalation of dosage can be attempted or an alternative PPI may be used. In our practice, we typically begin with up-titrating the PPI dose, although there is evidence to show that either approach can be effective [22].

Patients who continue to experience no or inadequate symptom improvement after high-dose PPI trials are considered PPI non-responders. Objective reflux testing should be performed in this population, as their lack of response may suggest an alternate cause for their symptoms. In this population, we prefer performing the combined pH-impedance testing while on acid suppression to help quantify any persistent reflux, the nature of reflux episodes (acidic vs. weakly acidic vs. alkaline), and symptom-association. If available, a dual channel pH catheter, with a pH channel at both the distal esophagus and the stomach, may provide further information regarding the adequacy of acid suppression by the PPI.

For patients with refractory reflux-type discomfort after fundoplication and who test positive for weakly acidic or non-acidic reflux on pH-impedance testing, a trial of oral GABA-B receptor agonist (e.g. baclofen) may be tried. Baclofen has been shown to reduce reflux episodes by decreasing the rate of transient LES relaxation, increasing basal LES pressure, and accelerating gastric emptying [23, 24]. However, baclofen is often associated with CNS side effects such as drowsiness that may limit its use. Surgical revision, including tightening of the fundoplication or repair of anatomic defects such as hiatal hernia, is often indicated in patients with persistent reflux confirmed on objective testing. In obese patients, conversion to bariatric surgery, specifically Roux-en-Y gastric bypass, may allow for better control of gastroesophageal reflux through weight loss and a decrease in transdiaphragmatic pressure gradient.