Evaluation of the Failed Anti Reflux Procedure

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As has been noted throughout this book, surgical anti-reflux procedures, when performed by an experienced surgeon, are effective in eliminating the symptoms of GERD in the vast majority of patients treated in this manner. Furthermore, because most patients treated surgically derive a durable effect, anti-reflux surgery provides healing and maintenance of remission.

Despite the high success rate achieved with antireflux surgery, many patients still will either fail to achieve an initial symptom response or experience a relapse of their GERD symptoms over time. The initial failure rate with antireflux surgery is likely much greater in less-experienced surgeons' hands, whereas later anti-reflux surgery "relapses" seem to occur even in patients treated by the most experienced surgeons. The mechanisms or reasons for persistent or recurrent reflux after anti-reflux surgery are not entirely understood. However, given the rapidly expanding use of this surgical procedure, it is clear that we increasingly have to manage patients who have failed anti-reflux surgery. The management options after failure of anti-reflux surgery are either to reinstitute medical anti-reflux therapy, consider performing one of the emerging endoscopic anti-reflux therapies, or perform a repeat anti-reflux surgical procedure.

In the past, the evaluation of a suspected failed anti-reflux surgical procedure likely consisted of a barium swallow and esophageal manometry. These anatomic and physiologic tests have largely been supplanted by or expanded to also include a careful endo-scopic assessment and prolonged ambulatory esophageal pH monitoring. We suspect that endoscopy or another means of directly imaging the suspected failed surgical repair will always remain a critical requirement of any postoperative evaluation strategy. However, it is interesting to speculate that nonendoscopic direct imaging of the surgical repair site might become an option in the not-so-distant future.

Recently, a 14 frame per second dual-headed capsule (PillCam; Given Imaging, Yoqneam, Israel) has begun initial testing as a means of evaluating the distal esophageal mucosa for evidence of esophagitis and or Barrett's esophagus. It is plausible that further developments with this noninvasive, office-based test could conceivably offer both an antegrade and retrograde detailed inspection of the surgical site and provide the necessary information the physician needs to assess competency of the original fun-doplication.19

Another potential means of imaging the wrap may be through the use of high-resolution computed tomography or magnetic resonance scanners using the newer and increasingly available multichannel systems along with software that


allows three-dimensional reconstruction and "fly-through" imaging of the gastrointestinal tract. Although most physicians have become aware of this technology as a means of evaluating the colon (computed tomography or magnetic resonance colonography or "virtual" colonoscopy), this technology can also be used to image the small bowel and stomach/esophagus. It is interesting to speculate that three-dimensional reconstruction with "fly-through" capability may allow for the same comprehensive antegrade and retrograde evaluation of an anti-reflux surgical repair that is currently only available endoscopically. Thus we may be able to obtain endoscopic-quality imaging of the suspected disrupted fundoplication noninvasively.

In addition to this fly-through capability for static constructs, increasing computing memory and speed may eventually permit dynamic evaluation of hollow organs in three dimensions at high magnification over time. The primary limitation of this technique will be the radiation dose required to complete the examination, which we estimate will require a period of 10-20 minutes of real time radiography during which patients are put through a variety of swallowing maneuvers. The information obtained would provide imaging at a level of complexity not currently available in any single test and in a noninvasive manner. The three-dimensional evaluation of a dynamic process, with the ability to reconstruct both the esophageal and gastric lumens (fly-through technology) and the fundoplication wrap ("drive-by" technology), would provide the clinician with the capacity to identify details such as inappropriate motion of the stomach within the wrap or which individual suture is creating excessive narrowing of the gastric lumen.

Although both of these above suggestions for imaging an anti-reflux surgical site may at first glance appear highly speculative, the progress made in gastrointestinal imaging with capsule devices and radiology over the last few years is simply staggering. It is entirely conceivable that comprehensive nonendoscopic imaging of the anti-reflux construct can be obtained with these or other advanced imaging technology in development, and we suspect the only real issue is how soon reliable imaging of this nature will become available for clinical use in evaluating a prior anti-reflux surgical repair.

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