Nissen fundoplication is a surgical procedure designed to treat severe gastroesophageal reflux disease (GERD) when medications and lifestyle changes have proven ineffective. The operation involves wrapping the upper part of the stomach (fundus) around the lower esophagus to reinforce the weakened lower esophageal sphincter (LES). This technique creates a physical barrier, preventing stomach acid from flowing backward and solving the mechanical problem causing chronic acid reflux. While highly effective, the procedure is subject to mechanical failure over time, often manifesting as a “slipped fundoplication.”
Understanding the Fundoplication and the Mechanism of Slippage
The original fundoplication surgery aims to restore the normal anatomy of the gastroesophageal junction by creating a new valve, or “wrap,” securely placed below the diaphragm. This wrap, typically a full 360-degree cuff of stomach tissue, reinforces the pressure barrier at the bottom of the esophagus. For proper function, the surgeon must mobilize the lower esophagus so that a segment of approximately three centimeters lies tension-free within the abdominal cavity.
A “slipped wrap” occurs when the newly created valve and the gastroesophageal junction migrate upward from the abdominal cavity back into the chest cavity. This migration, known as transmediastinal herniation, often drags the upper part of the stomach through the wrap or the diaphragmatic opening. When this happens, the stomach’s acid-producing tissue can become incorporated into the wrap, leading to severe inflammation and the return of reflux symptoms. This failure is primarily an anatomical breakdown, which can be an acute technical problem or gradual mechanical deterioration.
Primary Causes of Fundoplication Failure
Failure of the fundoplication is broadly categorized into issues stemming from the technical aspects of the surgery and factors related to the patient’s post-operative condition or physiology.
Technical factors during the initial surgery play a large part in the long-term durability of the repair. A frequently cited issue is inadequate mobilization of the esophagus, which leaves the wrap under tension and prone to being pulled back into the chest. Additionally, insufficient closure of the diaphragmatic opening, or crural repair, allows the stomach and the wrap to push through the enlarged hiatal opening. The quality of the wrap itself can also be a factor, with failure resulting from a wrap that was initially too loose, too tight, or even twisted.
Patient-specific factors also contribute significantly to the mechanical breakdown of the repair over time. Any condition that increases pressure within the abdominal cavity can place extreme stress on the fundoplication and the hiatal repair. Severe and chronic post-operative vomiting or retching, persistent coughing, and even strenuous physical exertion can push the stomach upward through the diaphragm. A high body mass index (BMI) and rapid weight fluctuations are associated with increased abdominal pressure and are known to be risk factors for fundoplication failure.
Recognizing the Signs of a Slipped Wrap
The symptoms of a slipped fundoplication are essentially a return of the conditions the surgery was meant to fix, often combined with new mechanical issues related to the failed wrap. The most common and direct sign is the recurrence of severe gastroesophageal reflux disease symptoms, such as heartburn and regurgitation, which indicates the barrier is no longer effective. This is often accompanied by the return of chronic inflammation in the esophagus.
Patients may experience dysphagia, or difficulty swallowing, if the wrap has migrated or become excessively tight. Other mechanical symptoms include:
- Abdominal pain and chest discomfort.
- A persistent inability to vomit or dry heave.
- Bloating and increased flatulence, often referred to as gas-bloat syndrome.
To confirm a slipped wrap, physicians use diagnostic tools like an upper endoscopy, a barium swallow study to visualize the anatomy, and pH monitoring to assess the severity of the recurrent acid reflux.
Treatment Options for Revision
Once a slipped Nissen fundoplication is confirmed, the management approach is determined by the severity of the failure and the patient’s overall health. For patients with mild symptoms, a trial of conservative management, including dietary changes and acid-reducing medication, may be considered initially. However, in most cases of confirmed anatomical failure, a surgical revision is necessary to correct the mechanical defect.
The goal of revision surgery is to dismantle the failed wrap, fully restore the normal anatomy, and construct a new, durable anti-reflux mechanism. Surgeons typically perform this re-operation using a minimally invasive laparoscopic approach, though open surgery may be required in complex cases. The procedure involves dissecting the old scar tissue, pulling the stomach back down into the abdomen, and repairing the hiatal hernia with a meticulous closure of the diaphragm.
During the revision, the surgeon may choose to create a new Nissen fundoplication or convert to a partial fundoplication, such as a Toupet procedure. A partial wrap is sometimes preferred to reduce the risk of post-operative difficulty swallowing, especially if the patient has underlying issues with esophageal movement. For patients with severe obesity, conversion to a Roux-en-Y gastric bypass may be considered, as it addresses both the reflux and the weight-related risk factors simultaneously.