Time, Genetics, and Other Factors
It’s important to remember that Severe GERD Surgery is different from other, more traditional surgeries performed on other areas of the body. This is because Severe GERD Surgery reconstructs an area of the body, called the esophageal gastric junction that is dynamic. This area moves with every breath. There is both physiologic and anatomic reasons why Failed GERD surgery occurs. When a surgeon initially repairs the LES and hiatal hernia the repair must be loose enough to allow food to pass. Time, genetics, and other factors may allow the repair to loosen over time. Some genetic predisposition or behaviors may also increase the risk of Failed GERD Surgery, like morbid obesity or a predisposition to get hernias due to weak fascia.
Recurrence of Hiatal Hernias
The number one reason for Failed Antireflux Surgery is the recurrence of a hiatal hernia. Hernias are weaknesses in the fascia, the gristle that holds muscle together. In the initial Antireflux Surgery the already weakened fascia of the esophageal hiatus can be damaged further during the dissection. This damaged fascia is what causes recurrent hiatal hernias. For nearly thirty years, surgeons have used mesh to replace the weakened or damaged fascia when repairing hernias in other parts of the body to prevent recurrence of the hernia. While some older mesh had issues, newer techniques and materials are safe to use in repairing a recurrent hiatal hernia. The mesh I designed is horseshoe shaped, reinforces the primary hernia repair, and does not touch the esophagus. Over a thousand cases in the last ten years have been performed using this mesh without a single esophageal problem occurring.
Different methods of performing the fundoplication or wrap are performed when reconstructing the lower esophageal sphincter (LES). For example, the TOUPET or partial wrap is used for people who have a weak esophagus. The NISSEN or complete wrap is performed in most patients with severe GERD. If the wrong wrap method is used, it may make GERD symptoms recur or become more severe. It’s important to note that since the area being repaired is dynamic, moving continuously with each breath, the wrap may slip over time leading to complications.
The initial workup performed by the surgeon prior to the first surgery is very important in preventing failure of the Antireflux Surgery. If the patient has an underlying condition, like a motility disorder, GERD surgery may fail due to treating only a symptom of a larger issue. Motility disorders are conditions that affect the spontaneous motion (peristalsis) that occur normally within our intestines. Achalasia is an example of a motility disorder that, if it’s not diagnosed preoperatively, may result in Failed Antireflux Surgery. Achalasia is a motility disorder where the LES will not relax properly. It can cause symptoms similar to GERD. If achalasia is misdiagnosed as Severe GERD, surgical treatment involving wrapping to strengthen the valve will actually make the condition worse.