Standard Anti Reflux Repairs

When a stricture is dilatable and the esophagus mobilized to the aortic arch, a proper partial fundoplication can usually be obtained and

MANAGING FAILED ANTI-REFLUX THERAPY

reduced under the diaphragm.13,14,37-39 Such repairs include the posterolateral Belsey Mark IV and the posterior gastropexy of Hill.

They were shown to offer satisfactory reflux control in 25-85% of treated patients with a follow-up of 16 months to 6 years. When a total fundoplication of the Nissen type was used to treat a strictured esophagus, the short-term success rate was reported to vary between 88 and 100%.40-42 However, long-term assessment of reflux-induced esophageal strictures in patients treated by a Belsey repair documented a failure rate of 45% in controlling reflux damage.14 Subsequent reports on Barrett's patients cohorts treated for their reflux complications by total fundoplication revealed an inappropriate failure rate of the operation.15,16 Repair of massive hernias using standard operations lead to the same dismal results as reported by Pearson et al.43 Low44 concluded that an unrecognized short esophagus with a repair under tension is responsible for this high failure rate: esophageal strictures, the columnar-lined esophagus, the failed repairs, and massive hiatal hernias should be considered as categories of esophageal problems at risk of failure when using standard surgical repairs.

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