Failed antireflux surgery: what have we learned from reoperations?
HYPOTHESIS: Factors that lead to failures in antireflux procedures can be identified, 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 anatomic 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 operations 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 symptoms 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 1, patients in whom the gastroesophageal junction was herniated through the hiatus, either with the wrap (IA) or without it (IB). There were 13 patients (43%) classified as having type IA, and 5 patients (16%) classified as having type IB. Type II failure involved a paraesophageal component resulting from a redundant wrap in 5 patients (16%), and type III involved a malformation (defective position or construction) of the wrap in 2 patients (6%). The remainder had a failed Hill fundoplication (3 patients), a herniated 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 surgical techniques including meticulous closure of the crura and appropriate construction and fixation of the wrap at the first operation will help prevent recurrence.