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June 2015

Analysis of the Causes of Failed Antireflux Surgery and the Principles of Treatment: A Review

Author Affiliations
  • 1Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
  • 2Department of Surgical Sciences, University of Torino, Torino, Italy
  • 3Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 4Boston VA Healthcare System, Boston, Massachusetts
JAMA Surg. 2015;150(6):585-590. doi:10.1001/jamasurg.2014.3859

Importance  Although the diagnostic evaluation and technical elements for a successful laparoscopic fundoplication have been clearly identified, 10% to 20% of patients will eventually experience recurrence of their symptoms. The management of patients who fail antireflux surgery is complex and not well codified.

Objective  To provide an evidence- and experience-based analysis of the causes of failed antireflux surgery and to underscore the principles of treatment.

Evidence Review  PubMed was searched for articles published between 1980 and 2014. The search terms included were the following: heartburn, regurgitation, dysphagia, gastroesophageal reflux disease, cough, aspiration, laryngitis, GERD, GORD, endoscopy, manometry, pH monitoring, proton pump inhibitors, and Nissen fundoplication.

Findings  Before planning therapy, a careful workup is necessary to determine whether the symptoms are due to recurrent reflux and to understand what caused the recurrence. Subsequently, therapy needs to be individualized based on the symptoms and on the findings of the workup. In some patients, a nonesophageal cause will be identified. Among patients with recurrent reflux, some will do well with acid-reducing medications and others will need another operation.

Conclusions and Relevance  Laparoscopic antireflux surgery is a very effective and long-lasting treatment for gastroesophageal reflux disease. Its success is based on a careful preoperative evaluation and on the performance of a fundoplication that respects the key technical elements. Patients who are still symptomatic postoperatively must be thoroughly evaluated to identify the cause of failure, and treatment must be individualized.

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