Patients with a slipped Nissen represent a difficult challenge. Those with a gastric pouch above the fundoplication will often have symptoms of severe reflux, regurgitation, and dys-phagia. Not only is food trapped in this pouch during swallowing, acid-rich refluxate pools in this pouch, immediately below an incompetent sphincter. These patients may develop severe erosive esophagitis, strictures, and even Barrett's esophagus if this problem is not alleviated. It should be no surprise that these patients are extremely grateful when the fundoplication is placed in the correct location on the esophagus. It may be impossible, preoperatively, for the surgeon to determine whether the fundoplica-tion has truly slipped, or whether it was misplaced initially. Reoperation in patients with a misplaced fundoplication often reveals that the mediastinal component of the esophagus, just
PERSISTENT SYMPTOMS AFTER ANTI-REFLUX SURGERY AND THEIR MANAGEMENT
above the gastroesophageal junction, was never mobilized during the first procedure and there is very adequate esophageal length to place the fundoplication higher up in the correct position. Alternatively, if the fundoplication is truly slipped onto the stomach, especially in patients with advanced esophageal disease, this may indicate a shortened esophagus which will need to be addressed with a gastroplasty. The operative principles will be discussed in another chapter.
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