The results for anti-reflux surgery are generally good, however, patients who have failed anti-reflux procedures constitute a particularly challenging group. Which of the following statement(s) is/are true concerning failed antireflux repairs?

a.A Slipped Nissen is usually the result of an operative technical mistake

d.Colonic replacement, although technically challenging, usually has superior long-term results when compared to esophageal replacement with the stomach

 When patients are correctly selected and the operation performed with conformity with the basic surgical principles, longterm relief of symptoms is achieved by more than 90% of patients. A number of patterns of failure, however, can occur. The so-called Slipped Nissen may develop when the upper stomach rides up through the fundoplication, and causes both dysphagia and heartburn. It is more likely that the condition was created at the time of surgery because the surgeon did not mobilize the fundus, or because unrecognized esophageal shortening led to inadequate mobilization of the gastroesophageal junction, causing the surgeon to wrap the stomach around the upper stomach rather than the lower esophagus. Creating too tight a fundoplication leads to immediate postoperative dysphagia. Manometry shows a high pressure nonrelaxing sphincter which may be difficult to distinguish from achalasia. Such patients highlight the importance of manometry in all patients before proceeding with anti-reflux surgery. In a patient with normal preoperative motility, the cause is usually a fault in technique, and can be prevented by constructing the fundoplication over a 60 F Bougie. Disruption of the fundoplication that manifests clinically and physiologically by recurrent reflux can be caused by inadequate suture technique, unrecognized esophageal shortening leading to tension on the wrap, or poor choice of operation. All partial fundoplications, such as the Toupet procedure are more prone to disruption than a Nissen. This is because the integrity of the repair depends on sutures to the esophageal wall and not the stomach, and because all these repairs require much more abdominal length of esophagus than a Nissen, thus placing the repair under tension. Esophagectomy and esophageal replacement are occasionally indicated in the treatment of advanced GERD. The indications for esophagectomy are Barrett’s esophagus with high grade dysplasia and what is generally described “burned out esophagus” which includes failure of a third anti-reflux operation, a severe coexistent motility disorder, or the presence of an undilatable stricture. Either colon or stomach may be used to replace the esophagus. Colonic replacement is more difficult, requiring three anastomoses rather than one, but it has superior functional long-term results.