I'm very sorry to hear you're struggling with LPR symptoms again. A few things have come to mind. First, you need to realize that a Nissen surgery will not stop absolutely all reflux from occuring. Rather, it is an attempt to bring reflux to a "normal" range. This can be a big problem for those of us who are very sensitive to reflux, as LPR sufferers are.
This is the reason that many GI docs are hesitant to offer the surgical option to those of us with atypical symptoms. We can have the surgery and continue to suffer from symptoms because there is no way to reduce reflux to zero. In order to do that, our wraps would have to be so tight that we wouldn't be able to swallow.
While typical GERD patients who are referred for surgery generally have extremely high levels of reflux as indicated by very high DeMeester scores, most with LPR have levels that are very close to normal. (I don't know what your was like, but my highest DeMeester was only borderline.)
So that's the conundrum. The surgery can make us better, but we can still react to whatever reflux slips through during those times when we overdo eating and drinking. Because of that, we'll be the post-Nissen patients who will need to behave as if we didn't have the surgery--taking the precautions that can help keep acid for causing problems--things like continuing to sleep with the head of our bed elevated, not eating less than 3 hours before bedtime, even continuing to take PPIs.
This is definitely something unique to some post-Nissen LPR patients. Prior to surgery, my lungs were out of control with serious asthma symptoms, and even persistent lung infections. I was even hospitalized as a result of GERD-induced uncontrollable asthma. Since my surgery my steroid intake is a mere fraction of what it was before surgery, and my lungs are much, much, much better.
That said, I still get some symptoms at times that are suspiciously LPR-like. Since I also have severe allergies, it's often hard to differentiate--frustratingly so, in fact. I don't get the irritated throat issue, but can have postnasal drip and some asthma symptoms that could be either allergy or LPR related.
So...I can say with confidence that my condition is much improved, but I still am quite sure I'm getting some silent reflux. Because of this I have to assume I'm getting reflux, and follow those old suggestions that were offered to us prior to our surgery.
Sure, it would be nice to be like those typical post-Nissen patients who throw away their GERD trappings and live their lives without the problems they faced before surgery. Life isn't as easy for those of us who are extremely reflux-sensitive.
1. You mentioned you swig Carafate 10 times a day. As a Carafate fan, I do think it's helpful, but the dosage is only 4 times a day...1 hr before and 2 hrs after eating. Also two hours before or after meds. If you're taking Carafate too close to your meds they won't be absorbed properly. For that reason the PPIs (and other meds) wouldn't be able to work for you.
2. Once your delicate tissues have been irritated. You mentioned "dietary indiscretions"...once you're burned tissue it takes a very long time to get them feeling better. You now have a wrap to help the process, but it's obviously not doing the whole job. You do need to eat carefully, like it or not.
3. I do think you should pursue a second opinion. You are obviously suffering, and need to get to the bottom of the situation. Do you live near a large medical center (Johns Hopkins, Cleveland Clinic, Mayo, etc.)? Generally in places like that there will be surgeons who are used to dealing with difficult cases.
Believe me, I know how hard it is to get satisfaction with the subtleties of LPR. I have severe allergies, and since LPR and allergy symptoms are very close, I'm always struggling with an allergist who seems quick to assign blame to my history of reflux/LPR symptoms when they're more likely allergic in nature. That said, I am fully aware of the blurred line, and therefore continue to take a dose of Protonix 40mg before dinner, and sleep with an elevated bed.
My allergist sent me to a Nissen surgeon and I had all the testing done only to get the same pronouncement that you did...the wrap is intact and there is no need for a redo.
You deserve to feel well. Sunbeam's suggestion of the Koufman diet might be worth a try. I don't know much about it, but I do know that some here have been helped while following it.
Do the research and see if you can find someone who can help you. If you can get referred to an ENT/LPR specialist, and find someone who in knowledgeable and can do some testing to see what's going on. You may have to travel, but you can't go on the way you are.
Wish I could help you more, Joe. Best of luck finding an answer.