Surgical management after failed antireflux operations

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Abstract
From 1973 to 1989, 117 (28%) patients underwent re-operation for failed antireflux surgery from a total of 413 esophagogastric operations for gastro-esophageal reflux disease. Seventy-eight patients who underwent re-operation before 1984 were reviewed in detail for classification and long-term outcome. Forty re-operations followed a failed Nissen fundoplication, while no other procedure was the most recent prior operation in more than 10 patients. Re-operation rates were 3% following prior surgery in our clinic for reflux disease other than stricture and 9.6% if the prior operation was done for stricture. There was no difference in re-operation rates for the Belsey Mark IV or Nissen fundoplication, the 2 most commonly used repairs. In each case, complete pre-operative evaluations included symptom score, radiography, endoscopy, and esophageal function tests. Based on the results, the 78 patients were classified as pure sphincter mechanism failure to stop reflux (n=14), pure esophageal clearance failure (n=12), combined sphincter mechanism failure and clearance failure (n=29), alkaline reflux (n=9), or no reflux but another condition found (n=14). Patients having symptoms following a prior Nissen fundoplication or Angelchik prosthesis insertion were more likely to have esophageal clearance failure than those having other repairs. The classification proved to be a useful guide to the need for and types of re-operation chosen. Among the 117 patients undergoing re-operation, there were 2 (1.7%) deaths within 3 months of surgery and 25 (21%) complications. Long-term results were directly related to the number of previous operations, with resection and intestinal interposition being the preferred procedure in patients having had 2 or more previous attempts at antireflux surgery.

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