Appropriate treatment of failed anti-reflux surgery may range from reassurance to reoperative therapy. Revisional surgery can be recommended when the preoperative evaluation identifies a surgically correctable problem corresponding to the patient's symptoms. In general, operations that have failed for technical reasons can be corrected by a second operation. The most appropriate surgical approach will depend on the patient's previous operation and the results of the preoperative evaluation (see Chapter 11).
For patients with persistent dysphagia, esophageal dilation should be the first line of therapy. Often, multiple dilations can loosen a
TECHNICAL SURGICAL FAILURES: PRESENTATION, ETIOLOGY, AND EVALUATION
tight, but properly oriented wrap. However, if dysphagia is caused by a tight crural closure, dilation usually will not work and reoperation is often necessary. Similarly, if the wrap is mal-positioned, conservative therapy is unlikely to provide benefit. Patients whose dysphagia fails to respond to 2 or 3 dilations should be suspected of having a poorly constructed wrap or an overly tight crural closure. Reoperation should be considered if symptoms persist for more than 3-4 months.
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