Nissen fundoplication and hiatal hernia repair procedure, when properly performed, is the most reliable, effective and safest treatment for acid reflux disease. The advent of laparoscopy has allowed the reflux surgeon great visualization of the gastro-esophageal anatomy. Consequently, the distal esophagus became more accessible to full mobilization. Esophageal mobilization is a key step in reflux surgery commonly missed by the general surgeon. Chronic GERD results in slow and progressive retraction of the esophagus into the chest. The purpose of hiatal hernia surgery is to reverse this process to re-establish normal anatomy prior to performing the fundoplication. Incomplete esophageal dissection and mobilization is the most common cause of anti-reflux surgery failure resulting in wrap migration into the chest or slipped fundoplication. Incomplete gastric fundus mobilization results in dysphagia, and wrap failure. It is the second most common cause of anti-reflux surgery failure.
Failed Nissen fundoplication and hiatal hernia repair surgeries require surgical revision. Laparoscopic revision surgery is the first line treatment since it allows greater visualization than open trans-abdominal surgery. laparoscopic revision is also associated with lower morbidity. However, conversion to an open approach is sometimes necessary due to severe scar tissue formation, inflammation and loss of normal tissue planes. The success rate of revision anti-reflux surgery is lower than primary repair. It decreases with each revision. Indeed, we prefer to offer gastric bypass surgery after the second revision as it offers better acid reflux control than a traditional Nissen fundoplication.
Patients presenting for recurrent acid reflux or dysphagia following Nissen fundoplication undergo complete GERD workup including upper endoscopy, 24-hour pH impedance, manometry, UGI and a gastric emptying study. Patients with gastroparesis, intact wrap and no hiatal hernia are offered a fundoplication preserving longitudinal gastrectomy along the greater curvature. I have had great success with such approach and I am currently extending the application to morbidly obese patients. Patients who underwent Nissen fundoplication surgery years ago for GERD and are suffering now from excess weight can safely undergo gastric sleeve surgery without the need to take down the fundoplication. A wrapped fundus is equivalent to a resected fundus from a weight loss perspective. The key is to resect most of the redundant posterior gastric fundus. I preserve 80% of the antrum when performing gastric sleeve surgery to promote gastric emptying and avoid mutilating the stomach.
In summary, anti-reflux surgery is safe and effective when properly performed. Avoiding short cuts and paying attention to small details are crucial to avoid revision surgery.