What if I’ve had a Nissen fundoplication, but my symptoms have come back?

About 40% of patients with prior anti-reflux surgery (laparoscopic Nissen fundoplication) eventually need to resume PPI medications for reflux symptoms. Furthermore, ~10-18% of patients with a prior Nissen fundoplication end up having symptoms that are bad enough that they require a repeat surgery. These symptoms may be recurrent reflux symptoms or long-term difficulty swallowing caused by the initial surgery.

Traditionally, if reflux symptoms have returned, and they cannot be controlled with medications, a surgical “redo” or revision of the prior stomach wrap may be performed.

A redo surgical fundoplication (or stomach wrap), however, can be challenging and complicated for even very experienced surgeons due to the presence of scar tissue. Consequently, a revision surgery carries increased potential to damage the esophagus, stomach, and surrounding structures such as nearby nerves. Apart from increased morbidity, revision fundoplication/wrap surgeries also have an even higher rate of symptom recurrence than the initial surgery. 

There are many reasons symptoms can return after an anti-reflux surgery. One reason is that the surgical wrap (of the stomach around the esophagus) loosens or becomes disrupted over time.

Because of the technical challenges and potential for structural damage during a “redo” anti-reflux surgery, we have introduced use of the transoral incisionless fundoplication technique as a less invasive method to re-tighten the prior surgical wrap. In cases where the surgical wrap has become too loose, thereby allowing more stomach acid to reflux back up into the stomach, the endoscopic therapy we perform may regain control of symptoms while avoiding a potentially complicated redo surgery.

Since there can be many reasons for reflux symptoms returning after an anti-reflux surgery, before pursuing any endoscopic treatment, we first ensure that patients have had appropriate evaluation for the cause of these symptoms.

These tests include an upper endoscopy, an endoscopic ultrasound (which lets us endoscopically look across the wall of the stomach to accurately determine the position of your surgical wrap relative to the diaphragm), testing of the acid levels within your esophagus, and assessment of the function of your esophagus during swallowing. Sometimes, persistent acid reflux after an anti-reflux surgery may also be related to poor emptying of the stomach that was not identified prior to your surgery or that exists as a result of nerve injury during the initial surgery. (If this is suspected, examination of how your stomach empties is important as well, since potential medical and endoscopic treatments also exist to promote emptying of the stomach.)

Once the aforementioned tests are completed, we can identify if the problem is a loosened or disrupted wrap that may respond to endoscopic treatment.

It can be very frustrating to have failure of a prior anti-reflux surgery. In lieu of facing another surgery with higher risk for complications, endoscopic intervention may be an option to achieve relief.

    1. Celasin et al. Laparoscopic revision surgery for gastroesophageal reflux disease. Medicine. 2017. Jan;96(1):e5779.
    2. Oor et al. Seventeen-year outcome of a randomized clinical trial comparing laparoscopic and conventional Nissen fundoplication: a plea for patient counseling and clarification. Ann Surg. 2017. Jul;266(1):23-28. 
    3. Al Hasmi et al. A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication? Surg Endosc. 2019. 33:243-251.
    4. Munie et al. Salvage options for fundoplication failure. Curr Gastroenterol Rep. 2019. Jul 25;21(9):41.
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