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Background: Parallel with the increasing number of laparoscopic anti-reflux operations there is increasing number of re-operative interventions for failed procedures. We have performed 316 re-operative procedures from Feb/1992 to Nov/2010. The aim of this study was to compare presenting symptoms, endoscopic findings and operative approaches over the years. Methods: A retrospective review of a prospectively maintained database was performed of patients who underwent re-operative intervention after one or more previous anti-reflux surgeries. After institutional board review the database and charts were reviewed and analyzed for presenting symptoms, pre-operative endoscopic findings and operative procedures. Results: There was a significant increase in the number of re-operative interventions over the years (first 5 yrs: 8 procedures, second 5 yrs: 63 operations, third 5 yrs: 105 operations, last 4 yrs: 140 operations). The procedure was the first re-operation in 289 cases, second in 25 cases, third in 1 case and in 1 case it was the fourth re-operation. We divided the 316 operations into two halves, the first 158 patients (Group 1) were operated on from 2/1/1992 to 6/5/2006, the second half (Group 2) was operated on from 6/15/2006 to 11/2/2010. The most common indications for a re-operative procedure were heartburn (27% and 26%) and dysphagia (33% and 28% in each group) and did not change over the years. Pre-operative upper endoscopy revealed a recurrent sliding hiatus hernia (> 2cm) in 61 and 71 patients, disrupted fundoplication in 74 and 89 patients, twisted fundoplication or two-compartment stomach in 20 and 26 cases, slipped fundoplication in 56 and 54 patients and a paraesophageal hernia in 32 and 37 patients in each group respectively. There was no significant difference in the pattern of failure over the years. Re-operation consisted of redo-fundoplication in 141 and 81 patients; Roux-en-Y reconstruction (RNY) in 14 and 70 patients and esophagectomy was performed in 3 and 7 patients, respectively. A significantly higher number of procedures were done laparoscopicaly in the second group (108 vs 80, p=0.001). A large hiatus hernia (> 2 cm) with a slipped fundoplication was found in 29 and 38 patients in the two groups. In this subset of patients a significantly larger number of RNY reconstructions were performed in the second group (3 vs 20, p=0.0003), while gastroplasty was used more frequently in the first group (8 vs 0, p=0.0001). Discussion: While there has been no significant change in the presenting symptoms and anatomical derangements encountered in patients undergoing re-operative intervention for failed fundoplication, a larger number of cases have been completed laparoscopically with an increasing utilization of RNY construction.