Nissen hiatal hernia repair: problems of recurrence and continued symptoms.

The standard Nissen operation is the most effective method of reflux control. However, the procedure can result in continuance of symptoms, particularly dysphagia, which presents considerable diagnostic difficulty. Experience gained in the management of 17 patients with continued recurrent symptoms following standard Nissen repair has allowed more specific definition of the nature of these problems. The anatomical defect has been categorized as follows: (1) tight repair (tight fundoplication or tight diaphragmatic repair); (2) anatomical recurrence with and without reflux; and (3) intussusception recurrence. Each patient has been evaluated by history, manometry, pH reflux, acid perfusion, radiology, and endoscopy. At the time of corrective operation, the previous repair was carefully dissected to allow confirmation of the type of defect. Correlation is made between symptoms, investigative findings, and the anatomical problem at operation.