[Surgical treatment of recurrent gastroesophageal reflux].

From 1972 to 1994, 66 patients underwent 67 Belsey MK IV antireflux repairs in our unit. Fifteen of the 67 patients or 22% had previously undergone antireflux surgery (10 hiatal repairs and 5 antireflux repairs). Obstructive symptoms were present in one patient who had previously undergone a Nissen fundoplication whereas all other patients presented recurrent reflux. There were no operative complications and only one hospital mortality (6.6%). Long-term results were good-to-excellent in 62% of all patients and fair in 15% of all patients; failures constituted 23% of all cases and were due to recurrent reflux symptoms. In the literature of the last 20 years, two groups can be identified, one group consisting of 142 patients treated surgically after unsuccessful Nissen fundoplication, the other group consisting of 438 patients who underwent 580 operations due to failure of the more common antireflux procedures used today. Recurrent reflux was the most frequent cause of failure in both groups (48% in the first and 58% in the second group). With respect to obstructing symptoms (26% and 32% respectively), these were due to a tight wrap in those patients who underwent a Nissen fundoplication and to peptic stenoses in those patients who underwent other surgical procedures. In 25% of patients who underwent a Nissen fundoplication, the cause of failure was the so-called "Slipped Nissen", responsible for both obstructing symptoms and reflux. In 60% of patients treated for failure following a Nissen fundoplication, the same surgical procedure was used. In the second group, only 20% of all patients underwent a Nissen fundoplication while 20% underwent esophageal resections and another 20% other antireflux surgical procedures. The differences in mortality and morbidity in the two groups (0-2% vs 0-12% and 0-33% vs 21-73%) are probably related to a higher incidence of the thoracic approach in the second group. Good-to-excellent results were achieved in 60-100% of patients treated for failure after a Nissen fundoplication and in 58-60% in those patients treated for failure of other various surgical procedures.