I had a fundoplication done by laparoscopy about 16 months ago. It is already apart. I am back to severe heartburn. Have you heard of them coming apart? Can they be redone?

Lori

Fundoplication is the surgical procedure used to treat gastroesophageal reflux disease (GERD). It is usually recommended for the following groups of GERD patients: those who have symptoms despite medical treatment, those who have complications such as strictures or ulcers of the esophagus, and those who do not want to take medications daily for the rest of their lives.

Fundoplication involves wrapping the upper part of the stomach (the fundus) around the lower esophagus to provide additional support to the sphincter that separates the stomach and esophagus. Until recently, this procedure was performed via an abdominal incision. Now, it is usually done using laparoscopic surgery, which uses a much smaller incision and allows for faster recovery. When performed by an experienced doctor, laparoscopic fundoplication eliminates reflux symptoms in more than 90 percent of patients.

There are potential complications with fundoplication. The long-term data on laparoscopic fundoplication are scant because the procedure has been done for less than 10 years. However, the most common complaints relate to difficulty in swallowing (dysphagia), usually due to an overly tight fundoplication. This occurs in about 4-5 percent of patients long-term. It can usually be managed by widening (dilating) the lower esophagus during endoscopy. Other complaints include a feeling of fullness (also due to an overly tight wrap), flatulence, diarrhea and recurrent reflux symptoms.

Recurrent reflux, your complaint, occurs in about 3-5 percent of patients and usually appears during the first two years after the operation. This may happen if the fundoplication "slips" -- meaning the stomach moves up through an overly loose wrap. Or the cause may be disruption, in which the sutures holding the wrap come undone.

The treatment of first choice in recurrent reflux is medical therapy with anti-acid medications such as omeprazole (Prilosec). The reflux is generally not as severe as it was before the fundoplication, and most patients respond to medications. In some people, repeat surgery may be recommended.

To determine the cause of a failed fundoplication, it is important to do a complete work-up with endoscopy, esophageal contrast and motility (muscular activity) studies, and acid studies. The results of these tests will help the surgeon plan the redo procedure.

You must keep in mind that the risk involved in a second procedure is higher than the first one because of scar tissue. Because of this, most surgeons perform the redo surgery using an open (abdominal) approach rather than a laparoscopic approach. Only surgeons with a great deal of expertise in laparoscopic fundoplication should perform a redo procedure by laparoscopy.