The Medical and Endoscopic Management of Failed Surgical Anti-reflux Procedures

Abstract

The current gold standard and most widely-applied surgical intervention in GERD is minimally invasive gastroesophageal fundoplication or laparoscopic Nissen fundoplication (LNF). Variations include partial (270°) vs total fundoplication (360°). Other variations of antireflux surgery include conventional or open Nissen fundoplication, anterior (Dor 120°) fundoplication, Toupet fundoplication, and Robot-assisted LNF [1]. Overall, surgery is a safe and effective modality for treatment of GERD with 80–90% of patients having relief of symptoms [2–5]. However, outcomes of anti-reflux surgery are variable and reported failure ranges from 2% to 30% depending on how “failure” is defined, e.g., required reoperation or resumed medical therapy. Similar variability of failure is reported for Nissen fundoplication performed for paraesophageal hernias in the surgical literature. Failure rates also depend on experience of the surgeon, with only a 50–60% success rate in less experienced centers [6, 7]. Up to 62% of patients who have had anti-reflux surgery report requiring proton pump inhibitor therapy in the long term [8]. In addition, up to 7.5% patients experience other symptoms such as dysphagia and bloating [9]. These patients are often managed medically and endoscopically with 1.6–9.6% needing re-operation [10, 11]. Newer surgical and endoscopic approaches to treatment of GERD are being introduced into the market. One such technique, Magnetic Sphincter Augmentation (MSA, LINX® Reflux Management System, Torax, St. Paul, MN), which involves laparoscopic placement of magnetic beads around the GE junction, was approved by the FDA in 2012. Retrospective studies show 97.8% improvement in GERD symptoms with MSA, similar to LNF [12], but a common side effect necessitating device removal is dysphagia. The device removal rate is 1–3%, with the outcomes for this technique improving with surgeon experience as was noted upon introduction of LNF [13, 14]. Thus with introduction of newer antireflux procedures, increasing rates of anti-reflux surgery, and ever-rising GERD prevalence paralleling the prevalence of obesity, it is expected that there will be an increasing number of patients with failed anti-reflux surgery needing medical, endoscopic or surgical management. In this chapter, we discuss medical and endoscopic management for patients with failed anti-reflux surgery, but not requiring surgical correction such as of slipped wraps and paraesophageal hernias.