The above approaches are generally successful for a rst time re-operation and even for most second time re-operations [46]. For second or third-time re-operations and in several additional situations, however, conversion to Roux-en-Y gastric bypass should be considered as the nal and denitive operation for a failed GEJ.Though seemingly drastic, repeated failure of paraesophageal hernia repair is discouraging both for patient and physician and leaves few options. The decision to convert to gastric bypass can be made pre-operatively or intra-operatively. There are several different described variations of bypass to consider, including gastrojejunostomy with or without concomitant gastrectomy, gastrojejunostomy with the fundoplica­tion in place, or esophagojejunostomy [47]. If the patient has experienced multiple operative failures, they are at high risk for subsequent failure and pre-operative planning should favor a bypass operation [48]. If the patient has a BMI of over 35 and has recurrence of a hernia, a consultation with the bariatric surgeons should be made, especially in the setting of comorbidities [49]. A two-stage procedure may even be considered where the hernia is repaired rst, then a weight loss procedure is performed second in order to reduce the likelihood of intra-operative injury [50]. Another indication for bypass is very poor or absent esophageal motility in the set­ting of recurrence. In addition, if there are extensive or multiple intraoperative inju­ries with poor tissue quality and concern for the adequacy of repair, thought should be given to a bypass procedure.