What are the causes of failure of Nissen's operation?
HJ. Stein, J.R. Siewert, H. Feussner (Munich)
Nissen fundoplication has become the most popular of the antireflux procedures in patients with gastroesophageal reflux disease. Recent series show a long-term success
Failure of Nissen fundoplication occurs when the patient, after the repair, experiences persistent or recurrent reflux symptoms, is unable to swallow normally, or suffers from upper abdominal discomfort or other gastrointestinal symptoms. The assessment of these symptoms and the selection of patients who need further surgery remains a challenging problem.
Recurrence or persistence of reflux symptoms (i.e., heartburn and regurgitation) and postoperative persistent dysphagia are the most common indicators for failure of Nissen fundoplication. Recurrent or persistent reflux symptoms and/or dysphagia occur in about 8% of patients after Nissen fundoplication. In a series of 50 patients who required reoperation after a failed Nissen fundoplication, heartburn and regurgitation were the most common presenting symptoms . The prevalence of persistent dysphagia showed a marked decrease after 1983 (Fig. 1). This may reflect a change in the operative techniques and a subsequent change in the reasons for failure of the antireflux procedure in the past 20 years. Weight loss and the so-called gas bloat syndrome were a rare cause of failure before and after 1983 (Fig. 1).
The quality, intensity and time course of the patients' symptoms cannot be used frequently to determine the cause of failure. A thorough diagnostic work-up is essential in each patient. This includes contrast radiography and endoscopy of the upper gastrointestinal tract as well as functional tests. Contrast roentgenography may identify the presence, status and location of the wrap. In general, motion-recording contrast radiography (i.e., cine- or video fluoroscopy) is preferable to standard barium swallows to delineate alterations in anatomy caused by the previous surgical procedure. Endoscopy with biopsy is essential to assess the presence of esophagitis. In addition, the state of the fundoplication can be determined by observing the typical
Figure I. .Presenting symptoms of patients requiring a redo antireflux procedure before and after 1993.
"Nissen nipple" on retroflexion of the endoscope . Manometry and 24-h esophageal pH monitoring are required to evaluate the function of the lower esophageal sphincter, assess motor abnormalities of the esophageal body and objectively quantitate the presence and amount of gastroesophageal reflux. Gastric denervation and emptying disorders should be evaluated with scintigraphic techniques .
Persistent or recurrent postoperative reflux symptoms are usually due a breakdown of the repair and can be treated by a repeat antireflux procedure or acid suppression therapy. In contrast, postoperative dysphagia or a combination of dysphagia and reflux symptoms may be due to a myriad of causes which include a too tightly constructed wrap, a slipped wrap, a wrap that has been placed too low around the proximal stomach, development of a stricture, the presence of a motor disorder of the esophageal body, or a combination of these factors (Fig. 2). These situations frequently can not be solved by a simple redo fundoplication .
Wrap disruption has become the most common cause of failure in the past 10 years . It frequently occurs early during the postoperative course . This reflects the widespread use of absorbable suture material when creating the wrap. Inadequate suture technique (i.e., taking inadequate bites of tissue) and insufficient mobilization of the fundus may also contribute to wrap disruption.
The creation of a too tight or too long wrap is manifested by persistent dysphagia starting immediately after the antireflux procedure. Postoperative manometry in these patients shows a high-pressure sphincter which does not relax on swallowing.
Figure 2. .Schematic representation of the reasons for failure of Nissen fundoplication: A) wrap disruption; B) too tight and too long wrap; C) "slipped Nissen"; D) wrap around the stomach; E) gastric denervation.
Manometry occasionally may also demonstrate simultaneous contractions in the esophageal body in these patients. Creation of a too tight or too long wrap was a common cause of failure prior to 1983. This was due to a misperception of the mechanism of action of a fundoplication. An increased awareness of the principles of constructing a fundoplication (i.e., careful fundic mobilization and construction of a short and loose wrap around a large bougie) has resulted in a marked decrease of too tight or too long wraps in the past years [6,7].
The so-called telescope phenomenon or "slipped Nissen" develops when the proximal part of the stomach slides through the wrap . A predisposition for the telescope phenomenon to occur is most often created at the time of surgery when the fundus of the stomach is not mobilized, or when unrecognized esophageal shortening and inadequate mobilization of the esophagus lead to a wrapping of stomach around stomach, rather than stomach around the lower esophagus. In this situation, dysphagia and heartburn are present immediately after surgery because of a partial obstruction and reflux from the acid producing proximal stomach which lies above the wrap.
Slipping of the wrap can also occur gradually during the postoperative period if the sutures are not passed through the esophageal wall or cardia. These patients usually complain of heartburn and dysphagia occurring after a symptom free postoperative interval.
Gastric denervation symptoms (i.e., abdominal fullness, meteorism, delayed emptying and/or diarrhea) result from damage to the vagus nerve during antireflux surgery. With meticulous surgical technique, vagal injury can be avoided completely.
Inappropriate patient selection will also lead to dissatisfaction of the patient postoperatively . This most often occurs when the operation has been performed for symptoms in the absence of objective documentation of the disease, or when the presence of a severe esophageal motor disorder (i.e., achalasia) is not realized. Careful assessment with 24-h esophageal pH monitoring and manometry in all patients, prior to considering antireflux surgery, will minimize the incidence of such problems.
This analysis of the reasons for failure of Nissen fundoplication indicate that several factors are essential for a successful outcome after fundoplication. These are: 1) the identification and careful selection of patients who might benefit from antireflux surgery; 2) a meticulous surgical technique; and 3) a sound understanding of the principles of antireflux surgery. Attention to these factors will avoid failures in most instances.