Management of Failed Anti-Reflux Surgery

Abstract

SUMMARY G ERD is the most common condition affecting the upper gastrointestinal tract. This is partly due to the declining incidence of peptic ulcer as the incidence of infection with Helicobacter pylori has reduced as a result of improved socioeconomic conditions along with a rising incidence of GERD in the last 20–30 years. The classical triad of symptoms is retrosternal burning pain (heartburn), epigastric pain (sometimes radiating through to the back) and regurgitation. Some patients present with less typical symptoms such as angina-like chest pain, pulmonary or laryngeal symptoms. Dysphagia is usually a sign that a stricture has occurred, but may be caused by an associated motility disorder. The purpose of esophageal objective testing is to determine if the patients’ symptoms are due to gastro esophageal reflux events and to define the severity of GERD and esophageal motility that will impact on the selection of the type of surgical therapy. The esophageal objective testing includes barium esophagram, upper endoscopy, esophageal manometry, esophageal pH monitoring, and MII-pH. Gastric emptying studies may be considered in patients with suspicious symptoms such as bloating and nausea. Barrett’s esophagus is suspected endoscopically when the Squamo columnar junction is located proximal to the anatomic GEJ, and the characteristic appearance of a “salmon pink color” mucosa is encountered in the lower esophagus. Most patients have a relatively benign form of GERD that is responsive to life style and dietary modifications and medical therapy, and do not need surgical treatment. Antireflux surgery should be considered in any symptomatic patients with a documented GERD by pH testing or MII-pH regardless of presence of esophagitis and/or a defective LES. This is particularly true in patients who have PPI-responsive symptoms or persistent symptoms despite maximal PPI therapy. It is important to note that a good response to PPI therapy is a good indicator of the excellent outcome following antireflux surgery. The primary goal of antireflux surgery is to safely restore the structurally defective gastroesophageal valve, to prevent its shortening with gastric distention while preserving the patient’s ability to swallow normally. A laparoscopic approach has been widely accepted, and the laparoscopic Nissen fundoplication is the procedure of choice for a primary antireflux surgery in the majority of patients with good esophageal motility and normal esophageal length. The goal of surgical treatment for GERD is to relieve the symptoms by restoring a mechanically defective gastroesophageal barrier. The reoperation for a failed repair has been more frequent. Previous studies have shown that the failure rates for open fundoplication range from 9 to 30%, whereas those for laparoscopic approach range from 2 to 17%.