Definition

Antireflux surgery is the procedure to restore the function of the lower esophageal sphincter (the valve between the esophagus and the stomach) and to prevent the reflux of acid and bile (non-acidic juice) from the stomach into the esophagus. The most common procedure to restore the function of the lower esophageal sphincter is a minimally invasive procedure called laparoscopic Nissen fundoplication.

Following an antireflux surgery, if patients present with recurrent symptoms (the same symptoms that were present prior to surgery), or if they present with new reflux-related symptoms, failure of the procedure should be considered.

Causes

Patients should be selected very carefully and should have a complete work-up prior to an antireflux procedure. The majority of failed antireflux procedures are the result of inadequate patient selection, or incomplete diagnostic work-up prior to surgery and failure in surgical techniques. The fundoplication (wrapping of the stomach around the esophagus) can be too tight, too lose, twisted, can herniate into the chest or be slipped (the stomach is wrapped around itself instead of around the esophagus).

Predictors of a successful antireflux procedure include the presence of the typical symptoms of reflux, such as heartburn and/or regurgitation, response to medical therapy, and a positive esophageal pH study (showing that there is acid inside the esophagus), the last one being the most important predictor of success. It is important to review the patient’s symptoms in detail, and to obtain a complete work-up, including, videoesophagram, esophageal pH assessment, esophageal motility study and upper endoscopy, in all patients who are candidate for antireflux surgery.

Symptoms

Patients can present with both typical (common) or atypical (uncommon) symptoms of reflux. The symptoms can be the same symptoms prior to surgery or new symptoms.

Typical (common) symptoms

• Heartburn (a burning sensation behind the breast bone)
• Epigastric pain (upper abdominal pain)
• Dysphagia (difficulty swallowing or the sensation that food is hanging up or not passing down into the stomach properly)
• Regurgitation of food or liquids, particularly when bending over or laying down, associated with a bitter taste in the mouth

Atypical (uncommon) symptoms

• Chest pain
• Hoarseness
• Cough
• Pneumonia

Diagnosis

It is crucial to obtain a complete work-up in patients who have recurrent symptoms (the same symptoms that were present prior to surgery), or new onset reflux-related symptoms after an anti-reflux procedure. One should start from step one, assess the patient’s symptoms prior to surgery, review all the studies that were performed prior to surgery, review the surgery itself and obtain a thorough assessment of symptoms and onset of symptoms following surgery. Subsequently, a full work-up should be obtained which includes:

• Videoesophagram
• Esophageal motility study
• Esophageal pH assessment
• 24-hour pH study. In patients with respiratory symptoms, additional measurement is made in the upper part of the esophagus to identify how much acid refluxes up into the mouth, pharynx and possibly into the windpipe causing respiratory symptoms and damage to the lungs.
• 48-Hour Esophageal pH testing with the Bravo capsule wireless system
• Upper endoscopy

Treatment

The “redo” operation should address the exact cause of failure and should be performed in specialized, high-volume centers by experienced surgeons. A first-time redo antireflux surgery can be performed by minimally invasive approach. The most common procedure will be a redo laparoscopic Nissen fundoplication. The procedure may need to be done via a laparotomy (an incision in the abdomen) in selected patients. If multiple surgeries have failed, an esophagectomy (esophageal replacement) may be required.