Given the poor correlation between symptoms and anatomic failure, a careful and thorough evaluation is warranted. A complete history and physical should be performed with particular attention to the patient's current symptoms. Are the symptoms similar to those experienced before the original surgery? Do symptoms of reflux or dysphagia predominate? Was there a precipitating event? Do antacid medications ameliorate the symptoms? The patient's original operative report should be obtained to clarify the type of fundoplication and extent of dissection. Any prior preoperative radiographs and physiologic test results should also be obtained and reviewed. If the patient's symptoms are identical to their prior symptoms of reflux, a 2-week trial of omeprazole at 40mg/d should be
TECHNICAL SURGICAL FAILURES: PRESENTATION, ETIOLOGY, AND EVALUATION
initiated. Symptoms that completely resolve on this regimen should raise suspicion for recurrent reflux. The patient can be offered a continued course of medical therapy as a reasonable option. Many patients feel so well after successful anti-reflux surgery, however, that they prefer another operation to a lifetime of medical therapy. If the patient does not respond to omeprazole or has symptoms of dysphagia, the work-up should proceed with more invasive monitoring and diagnostic studies in an attempt to elucidate the etiology of their symptoms.
A barium swallow should be the initial diagnostic study in the work-up of any symptomatic patient. This relatively noninvasive, inexpensive study will define the patient's anatomy and help clarify the relationship of the gastroesophageal junction to the hiatus. This study may also demonstrate gastroesophageal reflux and can detect evidence of delayed esophageal emptying. A barium swallow is particularly helpful when the patient presents with symptoms of dysphagia or pain and can help delineate a gross anatomic defect that might explain the patient's symptoms (Figure 8.2). However, the failure to visualize reflux on a barium study does not exclude the possibility that the patient is experiencing pathologic reflux. Because patients may have symptoms consistent with reflux without evidence of gastroesophageal reflux, a 24-hour pH study is important in patients whose anatomy seems to be intact. This functional study confirms the presence of pathologic gastroesophageal reflux. By maintaining a 24hour diary, the patient's subjective assessment of reflux can be correlated with monitored episodes of reflux. Patients who have "reflux" symptoms, but a normal 24-hour pH study, are likely to have another cause for their symptoms and will not benefit from refundoplication.
Upper gastrointestinal endoscopy should be routinely performed in evaluating patients who are symptomatic after a fundoplication. Endoscopy and barium swallows provide complementary information. In up to 10% of patients, an endoscopy will reveal an anatomic problem not appreciated by a barium swallow.6 In particular, endoscopic evaluation may reveal a "spiraling" or "twisting" of the wrap that may be missed by standard barium studies (Figure 8.3). Endoscopy also helps assess complications of gastroesophageal reflux such as esophagitis and Barrett's mucosal changes. The degree of these changes may impact the decision to reop-erate or treat medically.
Esophageal manometry should be routinely performed before considering reoperation. Manometry provides an objective means of assessing the location and resting pressure of the lower esophageal sphincter. It can also provide an assessment of the functional status of esophageal peristalsis and sphincter relaxation. Manometric studies are critical when
MANAGING FAILED ANTI-REFLUX THERAPY
evaluating the patient who presents with dys-phagia, as these patients may have a previously undiagnosed esophageal motility disorder. It may be particularly difficult to differentiate patients with misdiagnosed achalasia from those whose fundoplication is too tight causing secondary poor esophageal peristaltic function. Moreover, patients who initially had normal esophageal function before surgery may develop secondary achalasia after fundoplica-tion.7 If reoperative surgery is indicated, the type of fundoplication chosen may depend on the results of esophageal manometry. Patients complaining of dysphagia who are found to have poor esophageal motility probably should not be offered a 360° wrap.
Patients with persistent bloating, nausea, vomiting, abdominal pain, and early satiety should undergo gastric emptying studies. These symptoms may be secondary to previously undiagnosed gastroparesis. An injury to the vagus nerves may also lead to abnormal gastric function with rapid emptying of liquids and delayed emptying of solids. If gastroparesis is detected, the success rate of a reoperation is lower and a pyloroplasty should be performed.
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