Postoperatively, a full liquid diet is recommended for 7 days followed by a soft diet and prn anti-emetics for nausea and prevention of retching. Within the first 3 months, full liquid diet is restarted or continued if patients experience dysphagia. Rarely, naso-gastric tube feeding may be required. Between 1 and 3 months, endoscopic dilation with balloon or bougie may be performed for relief of dysphagia, guided generally by manometric findings of high residual pressures on manometry and delayed transit on impedance studies, but there are no specific studies to compare efficacy compared to pneumatic dilation which would stretch beyond the diameters of mucosal pathology.

Barium esophagram, endoscopy and manometry are useful in discerning the etiology of dysphagia. In those patients with normal barium esophagram and mild to moderate dysphagia, endoscopic dilation may be attempted. In those with severe dysphagia, without response to dilation, or evidence of anatomical abnormalities such as too tight of a wrap, slipped Nissen, paraesophageal herniation or ineffective peristalsis on manometry, re-operation may be indicated. This should be guided and substantiated workup including manometry, ambulatory pH, and endoscopy. Dysphagia after MSA is particularly common, and should be initially managed conservatively in absence of the red flags, as described above. Endoscopic dilation may help with symptom relief for persistent dysphagia after MSA placement, attributed to possible fibrosis. Refractory dysphagia will necessitate device removal laparoscopically, or readjusting the magnet ring. However, there is one case report of endoscopic removal of the device after erosion through the mucosa into the lumen [29].

Nausea is common in the post-operative period and is also managed conservatively with anti-nausea medications. Prolonged nausea beyond the immediate post-operative period may be due to gastroparesis. This can be confirmed with a gastric emptying study by traditional scintigraphy, SmartPill® test (GivenImaging), Gastric Emptying Breath Test (Advanced Breath Diagnostics, Brentwood, TN) or observation of retained food in the stomach during endoscopy despite patient reliably fasting overnight. Management is directed towards symptom control with small frequent meals, avoidance of fibrous and fatty meals, anti-emetics and prokinetics such as metoclopramide, promethazine, and ondansetron. Erythromycin has been used as promotilide in acute settings, but nausea and tachyphylaxis often limits its prolonged use. Naso-enteric feeding is rarely needed. A small proportion of patients may need surgical management with pyloroplasty or a subtotal gastrectomy with Roux-en-Y gastrojejunostomy. Gastric emptying study would also rule out dumping syndrome, which has been described in various post-fundoplication case reports, although the true prevalence after the surgery remains unknown.

Bloating after anti-reflux syndrome can be due to inability of the gastroesophageal junction to relax in response to gastric distention caused by either post-surgical changes or vagus nerve injury, gastroparesis, or aerophagia, which typically predates the surgery [30]. Symptoms typically improve over the first year after surgery. This can be managed with dietary interventions such as reduction in consumption of gas-producing foods or possibly initiating a popularized “Fermentable Oligo- Di- Monosaccharides and Polyol” (FODMAP) elimination diet, eating slowly to avoid aerophagia, gas-reducing agents such as simethicone, treatment of underlying conditions such as gastroparesis with prokinetic agents or SIBO with antibiotics, and assessment for bite malocclusion or replacement of ill-fitting dentures as potential causes of increased bloating. Patients who fail to respond to the above conservative measures or have debilitating symptoms may require surgical revision of their fundoplication.

Presence of gastroesophageal reflux should be confirmed by 24-h pH study with a positive symptom association probability in patients that experience recurrent heartburn or have atypical or extraesophageal manifestations of GERD. Medical management, endoscopic management and surgical revision are all options for patients with refractory or recurrent heartburn after anti-reflux surgery. Patient preference, presence or absence of underlying anatomical abnormalities and availability of surgical and endoscopic expertise will typically determine the course.

The decision to choose pharmacological therapy over surgical or endoscopic options is for the most part based on patient’s preference, their particular anatomy and physiology, as well as available local expertise. Medications are aimed largely to reduce symptoms or reduce caustic elements of the refluxate, but would not necessarily reduce reflux events for example in the setting of a slipped wrap, or reduce dysphagia associated with a paraesophageal hernia, for which surgical correction should be advised in most cases. However, pharmacologic therapy might be more cost effective than repeat surgery depending on patient age, or the main option in non-surgical candidates owing to comorbidities. Patients who have responded to proton pump inhibitor(PPI) therapy prior to surgery and now have a failed anti-reflux surgery with recurrence of GERD symptoms typically respond to resumed PPI therapy. In addition to PPI therapy, other classes of medications such as H2 receptor antagonists and antacids can be used in patients with milder and sporadic symptoms. Baclofen, a GABAB receptor antagonist, which reduces the number of transient lower esophageal sphincter relaxations (TLESR) can be helpful in a subset of patients with GERD, but often its use is limited by central nervous side effects such drowsiness, weakness, dizziness, confusion and insomnia, or systemic effects such as constipation and urinary retention. Also, the role of baclofen in patients who have had prior anti-reflux surgery is unclear. In some patients, ambulatory pH study and impedance testing may exclude acid or reveal non-acid reflux contributing to the GERD symptoms, and Symptom Association Probability may be helpful in identifying the cause of symptoms, even in the setting of overall normal pH scores (see Chap. 2). Patients with predominant alkaline reflux may be responsive to surface agents such as sucralfate or sodium alginate, as discussed in the Chap. 3. In the setting of normal impedance-pH testing and workup and presentation suggestive of functional heartburn and reflux hypersensitivity, neuromodulators such as low-dose tricyclic antidepressants, trazodone, serotonin-norepinephrine reuptake inhibitors, and selective serotonin reuptake inhibitors may be considered.

There have been several procedures that were developed for reinforcement of the lower esophageal sphincter for management of GERD based on an endoscopic platform. Several devices and techniques have been developed in the past few decades with the majority no longer available because of lack of efficacy or unfortunate serious adverse events, such as with injectable bulking agents, or from lack of financial survival of the company. The viable technology in use at this time include:

The Stretta procedure delivers RF energy to the deep muscle layer of the gastroesophageal junction and cardia, with subsequent wall thickening, increase in basal LES pressure, reduced LES compliance, decrease TLESRs, reduced refluxate volume, and improved GERD symptoms. This procedure has the longest track record of use, with over 20,000 procedures performed world-wide, four randomized control trials, and lowest complication rate of any non-medical treatment for GERD. The procedure is generally performed in an endoscopy unit without the need for general anesthesia or operating room. The Stretta procedure significantly reduced GERD HRQL, use of PPI drugs, esophageal acid exposure, LES pressure, and grade of esophagitis compared with sham control [31]. Up to 75% of patients who were on double dose PPI therapy were able to eliminate daily PPI therapy, with only occasional use of OTC medications after Stretta treatment [32]. At 10 year follow up, 72% of patients had normalization of GERD-HRQL scores, with 64% of patients achieving a 50% or more reduction in the medication use, of whom 41% were able to eliminate the use of PPIs completely [33]. Stretta appears to be a viable option for patients with GERD who choose an alternative to PPI therapy but not willing to undergo surgery. A prospective study of 217 patients with medically refractory GERD that underwent Stretta procedure included 15 patients with failed Nissen fundoplication who successfully had a Stretta procedure for relief of GERD symptoms. While there are no large studies specifically evaluating Stretta after failed fundoplication, this supports the feasibility and safety of Stretta in patients who have had failed anti-reflux surgery.