Multiple Failed Anti Reflux Operations

Another indication for esophagectomy for GERD is a history of multiple failed attempts at anti-reflux surgery. Compromise of esophageal blood supply occurs each time the esophagus and stomach are dissected to enable performance of a fundoplication. In addition, accumulated scar tissue as well as anatomic deformities caused by prior operations increase the risk of injury to the vagus nerves and the vagal plexus during dissection. The cumulative effect of these injuries results in loss of peristaltic function (pump function) leading to dysphagia and ineffective esophageal clearance of gastric refluxate. Several reports indicate that satisfactory results after fundoplication surgery occur in only 50-60% of patients who have had two or more prior fundoplications.22-24 The assessment of esophageal function is more important than merely counting the number of prior operations to determine optimal surgical therapy. Such assessment typically includes endoscopy, manometry, esophageal transit times measured by scintigraphy, gastric emptying time, and, in selected patients, esophageal pH monitoring may also provide useful information. In patients in whom pump function has been lost, strong consideration should be given to performing an esophagectomy.

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