The Nissen fundoplication is a surgical procedure designed to provide a lasting solution for severe gastroesophageal reflux disease (GERD) when medical therapy is no longer effective. This operation involves wrapping the upper part of the stomach, called the fundus, completely around the lower end of the esophagus to recreate a functional valve that prevents stomach contents from flowing back up. While highly effective for many patients, the physical reconstruction can occasionally fail or become structurally compromised over a period of time. Recognizing the specific signs that the surgically created wrap has loosened, slipped, or become otherwise disrupted is the first step toward appropriate medical intervention.
Understanding Fundoplication Failure
When a Nissen fundoplication “comes undone,” it means the anatomical repair has been altered. The most common forms of failure include wrap migration, slippage, or complete disruption.
Wrap migration, often called transdiaphragmatic herniation, occurs when the stomach wrap moves up into the chest cavity through the esophageal opening in the diaphragm. This movement can be partial or involve the entire wrap, and it essentially undoes the anti-reflux barrier created in the abdomen. A “slipped Nissen” is a specific type of migration where the gastroesophageal junction moves upward, pulling the stomach body through the fundoplication.
The result is that the lower esophageal sphincter (LES) is no longer properly supported or reinforced by the stomach wrap. This mechanical failure allows stomach acid and other contents to reflux back into the esophagus. Failure can range from a slight loosening of the wrap to a full disruption where the stomach tissue tears away from the esophagus.
Identifying the Primary Symptoms
The return of symptoms after a period of relief is the most noticeable indication that the fundoplication is compromised. These symptoms generally fall into two distinct categories: the return of acid reflux and new or worsening mechanical issues.
Return of Reflux Symptoms
Patients often experience a return of severe, persistent heartburn (pyrosis), which the surgery previously managed. This is frequently accompanied by the regurgitation of sour or bitter-tasting stomach contents, especially when lying down at night. Recurrent acid reflux can also lead to extra-esophageal symptoms, such as a chronic cough, hoarseness, or a sensation of a lump in the throat. The persistence of these symptoms signals that the antireflux mechanism is failing.
Mechanical and Obstructive Issues
The second category involves mechanical symptoms arising from the wrap’s physical movement or change in tightness. A common sign is new or worsening difficulty swallowing (dysphagia), particularly with solid foods. This occurs if a migrated or twisted wrap becomes too tight, creating an obstruction.
Patients may also notice the return or intensification of gas-bloat syndrome, characterized by uncomfortable abdominal distension and post-meal fullness. Since the original fundoplication prevents gas from escaping, a failed wrap can cause a partial obstruction that traps air, leading to the inability to belch or vomit. This inability to vent gas is a specific warning sign of a structural issue.
In rare instances, severe wrap migration can lead to a paraesophageal hernia, where the stomach herniates into the chest and may become twisted. This condition presents with acute symptoms, including sudden chest pain or rapid-onset difficulty swallowing. Any new or recurring symptoms require prompt medical attention, as they suggest the protective function of the fundoplication has been lost.
Diagnostic Confirmation and Next Steps
If a patient suspects fundoplication failure due to symptom recurrence, they should contact their surgeon or a gastroenterologist specializing in foregut disorders. Self-treating is not recommended, as the underlying structural issue requires professional evaluation. The medical team will use specialized tests to confirm the failure and determine its exact anatomical cause.
The primary diagnostic tools include an upper GI series, often called a barium swallow, which uses X-ray imaging to visualize the anatomy of the esophagus and the gastric wrap. This study is effective at showing wrap migration, slippage, or the recurrence of a hiatal hernia, often revealing an “hourglass” appearance of the stomach. An esophagogastroduodenoscopy (EGD) is also frequently performed, involving a flexible camera inserted through the mouth to directly inspect the integrity of the fundoplication and rule out other causes like ulcers or strictures.
Additional tests may include esophageal manometry to assess the strength and coordination of the esophageal muscles, and a 24-hour pH monitoring test to measure the amount of acid refluxing into the esophagus. Once the failure is confirmed and its mechanism identified, treatment options are discussed. Depending on the severity of the failure and the patient’s overall health, this may involve alternative medical management or, frequently, a revision surgery where the original fundoplication is taken down and rebuilt.