Management of the "Failed Nissen"

Laparoscopic Nissen fundoplication has become the gold standard in the surgical treatment of gastroesophageal reflux disease (GERD). As growing cohorts provide long-term follow-up, surgeons face larger numbers of patients presenting with symptoms that suggest a failed antireflux procedure. Evaluation of such patients should include a thorough assessment of subjective symptoms, past operative information, and objective data. Dysphagia, heartburn, and other complaints are best quantified according to standardized measures such as the GERD Healthcare-Related Quality of Life index or Gastrointestinal Symptom Rating Scale. Initial studies should include at a minimum barium esophagogram and esophagogastroduodenoscopy to diagnose the most common anatomical variants of failure. Esophageal manometry and 24-hour pH monitoring are also useful in select groups. Depending on the mechanism of failure, medical management, serial balloon dilations, and radiofrequency energy delivery to the lower esophageal sphincter may obviate the need for surgical reintervention, providing good outcomes and lowering morbidity in certain populations. When redo fundoplication is undertaken, critical principles include identification of the gastroesophageal junction, adequate mobilization of the esophagus, protection of the vagus, complete reduction of hernia contents, and proper dissection of the crura with preservation of the muscular fascia at the hiatus. In properly selected patients, reoperation for GERD can provide excellent short-term outcomes with acceptable success rates at 14-40 months (75%-85%) and high patient satisfaction.