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Background: Results after reoperative anti-reflux surgery (Re-ARS) are known to be inferior to primary intervention but little is known about predictors for poor outcome. The aim of this study was to understand the potential preoperative risk factors that lead to persistent postoperative heartburn (HB) along with low patient satisfaction. Methods: After IRB-approval, a prospectively maintained database was retrospectively reviewed to identify patients with >1 year of follow-up after Re-ARS. HB severity was graded 0-3 before and after Re-ARS based on responses to a standardized questionnaire. Patients reporting symptoms of grade 2 or 3 were considered to have significant HB. Satisfaction with Re-ARS outcome was graded using a 10 point analog scale.Results: Between December 2003, and September 2008, 110 patients underwent Re-ARS by a single surgeon (SKM). Significant pre-operative HB was reported by 52 (47.3%) patients and impaired esophageal motility was noted in 31 (28.2%). Remedial surgery included redo-fundoplication (n=90, 81.8%), Collis gastroplasty with redo-fundoplication (n=16, 14.6%), take down of the fundoplication only (n=3, 2.7%), and hiatal closure after lysis of dense adhesions (n=1, 0.9%). At least one year of follow-up (mean 21.8 months) was available for 94 (85.5%) patients. In patients with significant pre-operative HB (n=46) the mean symptom score declined from 2.21 to 0.6 (p<0.0001) Fourteen (14.9 %) patients reported significant postoperative HB. Of these, 10 patients reported persistent HB and four had new-onset appearance of the symptom. Univariate logistic analysis indicated that postoperative HB is significantly associated with preoperative esophageal dysmotility (OR: 6.9 CI 1.5-16.8). Multivariate logistic regression identified the esophageal dysmotility (OR: 7.83 CI 1.5-16.8) and the preexisting HB (OR: 3.86 CI 1.005-14.48) as a risk factors for significant postoperative HB. The overall satisfaction score was 8.3 and 91% of patients would recommend the procedure to a friend. Patients with good esophageal motility and without preoperative HB were significantly more satisfied with the results (8.7) than those with impaired esophageal motility and significant preoperative HB (6.9; p=0.007).Conclusion: Although HB is a common symptom among patients requiring Re-ARS, the reoperative intervention provides significant benefit. Patients with impaired esophageal motility - especially those with significant preoperative HB - are at increased risk for poorer outcomes and decreased satisfaction following Re-ARS.