Recurrent reflux and wrap disruption after Nissen fundoplication: detection, incidence and timing

One hundred and twenty-five patients with refractory gastro-oesophageal reflux disease underwent floppy Nissen fundoplication. Median follow-up was 52 months, and included endoscopy, manometry and prolonged pH recordings in all cases in addition to clinical assessment. Using objective criteria, 12 patients (9.6 per cent) developed recurrent reflux. In nine of these patients, endoscopy had suggested that the Nissen fundoplication had disrupted; wrap disruption was confirmed in seven patients who underwent reoperation. The median time to endoscopic recognition of wrap disruption was 7 months (range 3-10 months). In contrast, of 115 patients with endoscopic evidence of an intact fundoplication, only 3 (2.6 per cent) had recurrent reflux. Endoscopy allowed reliable differentiation between those with and without reflux control after operation (P less than 0.001). These results suggest that recurrent reflux after Nissen fundoplication is due to wrap disruption. This phenomenon occurs within the first postoperative year and can be recognized by informed endoscopic assessment.