Failure of antireflux surgery: Causes and management strategies

BACKGROUND: With wider use of laparoscopic antireflux surgery, failed antireflux procedures are likely to become more common. METHODS: The causes of failure, management strategies, and outcome were analyzed in a consecutive series of 105 patients with failed antireflux procedures. RESULTS: Recurrent reflux was the most common primary symptom for referral (44.7%), followed by dysphagia (32.3%), and a combination of dysphagia and reflux (15.2%). The reasons for failure were disruption of the initial antireflux procedure (46%), a displaced repair (23%), a too-tight or too-long fundoplication (10%), an unrecognized motor disorder (9%), a paraesophageal or axial herniation (6%), or gastric denervation (6%). Revisional surgery was required in 71 patients, and 34 patients were managed conservatively. Intraoperative assessment during reoperation showed that technical errors during the initial procedure were responsible for failure in 40 of 71 patients. With an individual therapeutic approach, good results were achieved in 86% of patients undergoing revisional surgery. CONCLUSIONS: Technical factors and inappropriate patient selection are the most common reasons for failure of antireflux surgery. An individual therapeutic approach based on an exact analysis of the reasons for failure of the initial procedure is essential for the successful management of these patients.