title: When fundoplication fails: redo?
abstract: OBJECTIVE
  The largest series in the literature dealing with redo fundoplication was presented and published in 1999 and included 100 patients. Herein we update this initial series of 100, with 207 additional patients who have undergone redo fundoplication (n = 307).
  
  
  BACKGROUND
  Increasing numbers of patients are failing esophagogastric fundoplication and requiring redo procedures. Data regarding the nature of these failures have been scant.
  
  
  METHODS
  Data on all patients undergoing foregut surgery are collected prospectively. Between 1991 and 2004, 307 patients underwent redo fundoplication for the management of anatomic complications or recurrent GERD. Statistical analysis was performed with multiple chi2 and Mann-Whitney U analyses, as well as ANOVA.
  
  
  RESULTS
  Between 1991 and 2004, 1892 patients underwent primary fundoplication for GERD (1734) or paraesophageal hernia (158). Of these, 54 required redo fundoplication (2.8%). The majority of failures (73%) were managed within 2 years of the initial operation (P = 0.0001). The mechanism of failure was transdiaphragmatic wrap herniation in 33 of 54 (61%). In the 231 patients who underwent fundoplication elsewhere, 109 had transdiaphragmatic herniation (47%, P = NS). In this group of 285 patients, 22 (8%) required another redo (P = NS). The majority of the procedures were initiated laparoscopically (240/307, 78%), with 20 converted (8%). Overall mortality was 0.3%.
  
  
  CONCLUSIONS
  Failure of fundoplication is unusual in experienced hands. Most are managed within 2 years of the initial operation. Wrap herniation has now become the most common mechanism of failure requiring redo. Redo fundoplication was successful in 93% of patients, and most could be safely handled laparoscopically.
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA. csmit27@emory.edu
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Smith
authors.forename: David A
authors.initials: DA
authors.lastname: McClusky
authors.forename: Murad Abu
authors.initials: MA
authors.lastname: Rajad
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Lederman
authors.forename: John G
authors.initials: JG
authors.lastname: Hunter
mesh_terms: D018662:Fundoplication / Q000009:adverse effects / Q000379:methods; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006551:Hernia, Hiatal / Q000601:surgery; D006801:Humans; D007902:Length of Stay; D012086:Reoperation; D017211:Treatment Failure