Identification of risk factors for postoperative dysphagia after primary anti-reflux surgery

Clinical and functional factors influencing the outcome of laparoscopic Nissen fundoplication

BACKGROUND AND AIM

Laparoscopic Nissen fundoplication (LNF) is the gold standard of antireflux surgery. Up to 30% of patients experience symptoms after surgery, with insufficient information available. The main objective is to evaluate epidemiological, clinical, and functional factors associated with symptoms after LNP.

METHODS

a retrospective case-control study including 79 operated patients (2015-2024). We assessed the relationship between epidemiological data, functional tests, and imaging study results with the occurrence of symptoms after LNF.

RESULTS

24 asymptomatic and 55 symptomatic patients were included. Functional and imaging tests were normal in the majority of asymptomatic patients. IRP-4s (95th percentile) in asymptomatic patients is 20.4 mmHg. Female gender (OR 4, 95%CI; 1.1-14), preoperative dysphagia (OR 8.2, 95%CI: 1.4-47.6), and IRP-4s (OR 1.2, 95%CI: 1-1.3) are independent factors for postoperative dysphagia. Type-III esophagogastric junction morphology on high-resolution manometry (OR 6.1, 95%CI: 2.1-18.1) is independently associated with GERD symptoms. AET showed a trend toward being an independent factor but did not reach statistical significance (OR 1.1, 95%CI:1-1.3). Hiatal hernia in the esophagogram was associated with reintervention (OR 5.5, 95%CI: 1.6-19.1).

CONCLUSIONS

Asymptomatic patients mostly have normal functional tests after LNF, although IRP-4s normal value (95th percentile) is higher than proposed in the Chicago Classification. Preoperative dysphagia and female gender are independent factors for postoperative dysphagia, which should be considered in the preoperative assessment. Functional and imaging tests are essential in evaluating patients with postoperative symptoms. Dysphagia is associated with higher IRP while GERD symptoms are related to type-III-EGJ on HRM. Similarly, a hiatal hernia on the esophagogram is associated with reintervention.

Utilization of Instrumentation in Swallowing Assessment of Surgical Patients during COVID-19

The aim of this study is to describe a measured return to instrumental dysphagia assessments for our vulnerable surgical patient population, such that best practice patterns could be resumed and our staff kept safe from transmission of COVID-19. A retrospective medical record review provided data on clinical practice patterns of swallowing assessment in an at-risk surgical patient population. Outcomes of this study support protocols that allow clinicians to safely resume the use of instrumental assessment and return to best practice in dysphagia assessment for our surgical patient population.

Association of Bolus Transit Time on Barium Esophagram With Esophageal Peristalsis on High-resolution Manometry and Nonobstructive Dysphagia

GOAL

The goal of this study was to correlate upright and prone bolus transit time (BTT) on barium esophagography (BE) with esophageal peristalsis on high-resolution manometry (HRM) and self-reported dysphagia in patients with normal lower esophageal sphincter parameters on HRM.

BACKGROUND

BTT on BE could be the gold standard for assessing the effectiveness of esophageal peristalsis if it can be quantified.

MATERIALS AND METHODS

Patients with normal lower esophageal sphincter parameters and standard-protocol BE from 2017 to 2020 were included. Patients were divided, based on the number of normal swallows (distal contractile integral >450 mm Hg-s-cm), into 11 groups (10 normal swallows to 0 normal swallows). Liquid barium swallows in prone position were objectively evaluated for prone BTT. Patients reported difficulty in swallowing on a scale from 0 (none) to 4 (very severe). Fractional polynomial and logistic regression analysis were used to study the association (along with the rate of change) between BTT, peristalsis, and dysphagia.

RESULTS

A total of 146 patients were included. Prone BTT increased as the number of normal swallows decreased ( P <0.001). Two deflection points were noted on the association between peristalsis and prone BTT at 50% normal swallows, 40 seconds and 30% normal swallows, 80 seconds, after which peristaltic function declined independently of prone BTT. Patients with prone BTT>40 seconds had nearly 6-fold higher odds of 0% normal swallows on HRM than patients with prone BTT<40 seconds ( P =0.002). Increasing prone BTT was associated with increasing dysphagia grades 1 and 2 ( P ≤0.036).

CONCLUSIONS

Esophageal motility can be quantified by BE. Prone BTT correlates with the proportion of normal esophageal swallows and dysphagia.

Management of Recurrent Paraesophageal Hernia

Introduction: Recurrent paraesophageal hernias (rPEH) represent a clinical and surgical challenge. Even with a relatively high incidence, most of them are minimally symptomatic, and the need for reoperation is low. For those patients who are candidates for surgery, laparoscopic revision is a feasible and safe technique although there are other treatment options available. Methods: This article provides an overview of the definition, mechanisms of recurrence, epidemiology, clinical presentation, and indications for treatment of rPEH, as well as an overview of the surgical management options and a description of the technical principles of the repair and/or resection. Results: Surgeons should consider multiple factors when deciding the appropriate treatment of patients with rPEH, and all of them require a complete and comprehensive evaluation. The surgical options need to be individualized and include a redo PEH repair and revisional fundoplication, a partial or total gastrectomy with Roux-en-Y reconstruction, or an esophagectomy. There are key steps during the surgical repair that contribute to a successful operation and also auxiliary techniques that can improve postoperative outcomes. After laparoscopic redo most patients have improvement of their symptoms and an acceptable rate of perioperative complications when they are performed by experienced foregut surgeons. In obese patients with rPEH, bariatric surgery can be the best treatment option. Conclusions: Laparoscopic reoperative management should be considered in symptomatic patients who are not controlled with maximal nonoperative therapy, after a thorough work-up and appropriate counseling. In cases with multiple hernia repairs, it is important to consider alternative operations.

Pneumatic dilation for persistent dysphagia after antireflux surgery, a multicentre single-blind randomised sham-controlled clinical trial

OBJECTIVE

There is no evidence-based treatment for persistent dysphagia after laparoscopic fundoplication. The aim of this study was to evaluate the effect of pneumatic dilation on persistent dysphagia after laparoscopic fundoplication.

DESIGN

We performed a multicentre, single-blind, randomised sham-controlled trial of patients with persistent dysphagia (>3 months) after laparoscopic fundoplication. Patients with an Eckardt symptom score ≥4 were randomly assigned to pneumatic dilation (PD) using a 35 mm balloon or sham dilation. Primary outcome was treatment success, defined as an Eckardt score <4 and a minimal reduction of 2 points in the Eckardt score after 30 days. Secondary outcomes included change in stasis on timed barium oesophagogram, change in high-resolution manometry parameters and questionnaires on quality of life, reflux and dysphagia symptoms.

RESULTS

Forty-two patients were randomised. In the intention-to-treat analysis, the success rates of PD (7/21 patients (33%)) and sham dilation (8/21 patients (38%)) were similar after 30 days (risk difference -4.7% (95% CI (-33.7% to 24.2%) p=0.747). There was no significant difference in change of stasis on the timed barium oesophagogram after 2 min (PD vs sham: median 0.0 cm, p25-p75 range 0.0-4.3 cm vs median 0.0 cm, p25-p75 range 0.0-0.0; p=0.122) or change in lower oesophageal sphincter relaxation pressure (PD vs sham: 10.54±6.25 vs 14.60±6.17 mm Hg; p=0.052). Quality of life, reflux and dysphagia symptoms were not significantly different between the two groups.

CONCLUSION

Pneumatic dilation with a 35 mm balloon is not superior to sham dilation for the treatment of persistent dysphagia after fundoplication.

Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter?

BACKGROUND

Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia.

METHODS

A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected.

RESULTS

The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit.

CONCLUSION

One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.

Clinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia

BACKGROUND & AIMS

Dysphagia is a consequence of antireflux surgery (ARS) for gastroesophageal reflux disease (GERD). We studied patient management and symptomatic outcomes.

METHODS

We performed a retrospective study of 157 consecutive adult patients with GERD (mean age, 65.1 ± 1.0 y; 72% female) who underwent ARS at a tertiary care center from 2003 through 2014. We characterized postfundoplication dysphagia using a self-reported Likert scale, which ranged from a low score of 0 (no dysphagia) to a high score of 4 (severe daily dysphagia); scores of 2 or more indicated clinically significant dysphagia. Postfundoplication dysphagia was categorized as early (≤6 wk after ARS) or late (>6 wk after ARS), and Kaplan-Meier analyses were used to assess the time to development of clinically significant dysphagia. We performed univariate and multivariate analyses to assess management response and identify factors associated with dysphagia. The primary aim was to determine the prevalence and clinical course of postfundoplication dysphagia in patients with GERD treated with ARS.

RESULTS

Of the 157 patients, 54.8% had early postfundoplication dysphagia (clinically significant in 20.4%); only 3.5% required endoscopic intervention. Over 2.1 ± 0.2 years of follow-up evaluation, 29 patients (18.5%) developed late postfundoplication dysphagia. Based on Kaplan-Meier analysis, the median time to clinically significant late postfundoplication dysphagia was 0.75 years (95% CI, 0.26-1.22). Of 13 patients (44.8%) who underwent endoscopic dilation, improvement was reported by 92.3%, with a mean decrease in dysphagia severity of 1.55 ± 0.3, based on the Likert scale. Prefundoplication dysphagia, early postfundoplication dysphagia, recurrent hiatal hernia, and lack of contraction reserve following multiple rapid swallows were univariate predictors of late postfundoplication dysphagia (P ≤ .04); lack of contraction reserve was associated independently with late postfundoplication dysphagia, based on multivariate logistic regression analysis (odds ratio, 3.73; 95% CI, 1.11-12.56).

CONCLUSIONS

Early and late postfundoplication dysphagia can be successfully managed conservatively or with endoscopic dilation, respectively. Lack of contraction reserve on multiple rapid swallows is associated independently with late postfundoplication dysphagia.

[Redo surgery after laparoscopic fundoplication]

OBJECTIVE

To analyze the results of redo surgeries after previous laparoscopic fundoplication.

MATERIAL AND METHODS

A retrospective analysis included 37 repeated anti-reflux surgeries. Control group consisted of 38 patients after the first anti-reflux surgery performed on the same clinical base. The causes of unsatisfactory results of the first operations were studied. Intraoperative data, immediate and long-term results of surgical treatment were compared in both groups. Quality of life in both groups was studied before surgery and in long-term period using GIQLI questionnaire.

RESULTS

The most common cause of recurrent reflux was a hernia recurrence combined with slipping or destruction of the fundoplication cuff. Dysphagia was usually a result of compression of the esophagus by tightly sutured diaphragmatic crura and recurrent paraesophageal hernia. The main group was characterized by significantly greater surgery time, hospital-stay, incidence of intraoperative and postoperative complications. However, a more significant improvement of quality of life (∆GIQLI) was observed in the main group due to the low QOL index before redo surgery.

CONCLUSION

Redo surgeries are effective and safe procedures. These operations significantly improve QOL in long-term period despite certain technical difficulties. Repeated surgeries for dysphagia accounted for 2%, for recurrent reflux - 6%. Persistent postoperative dysphagia is usually associated with diaphragm repair rather fundoplication cuff. Reflux recurrence is often caused by cuff slippage and recurrent hernia.

Preoperative High-Resolution Manometry Criteria are Associated with Dysphagia After Nissen Fundoplication

BACKGROUND

Dysphagia after Nissen fundoplication is challenging for patients. High-resolution manometry (HRM) has rarely been studied preoperatively to determine whether manometry values correlated with postoperative dysphagia after fundoplication. We aim to determine whether HRM criteria could predict dysphagia after Nissen fundoplication.

METHODS

A retrospective review of single-institution laparoscopic Nissen fundoplications (LNF) from 2013 to 2015 was completed. Dysphagia was graded using a standard scale. Four groups were: those with new postoperative dysphagia (ND), never had dysphagia (NV), continued dysphagia (CD), and resolved dysphagia (RD). Manometry criteria included distal contractile integral (DCI), contraction front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP), percent peristalsis (PP), and distal esophageal contraction amplitude (DECA). Statistical bootstrapping was used to power sample sizes for ANOVA analysis.

RESULTS

Ninety-four patients were included in the original cohort. Statistical bootstrapping sample size was 2992 patients. Among patients who did not have dysphagia prior to LNF, no HRM metric was associated with developing new dysphagia. Among those with dysphagia prior to LNF, a higher DCI, CFV, DL, PP, and DECA were associated with resolution of dysphagia. The RD group was 2.77 times more likely to have a DCI ≥ 1000 mmHg-s-cm compared with the CD group.

CONCLUSIONS

HRM criteria could not predict the development of postoperative dysphagia. However, in those with preoperative dysphagia and strong manometry criteria, dysphagia is more likely to resolve after Nissen fundoplication. Meanwhile, in those with preoperative dysphagia and weak manometry, dysphagia may persist and these patients may be better served with a partial fundoplication.

Persistent Dysphagia Rate After Antireflux Surgery is Similar for Nissen Fundoplication and Partial Fundoplication

BACKGROUND

Laparoscopic fundoplication is the gold standard operation for treatment of gastroesophageal reflux disease (GERD). It has been suggested that persistent postoperative dysphagia is increased following Nissen fundoplication compared to partial fundoplication. This study aimed to determine risk factors for persistent postoperative dysphagia, specifically examining the type of fundoplication.

METHODS

Patients experiencing GERD symptoms who underwent laparoscopic Nissen, Toupet, or Dor fundoplication from 2009 to 2016 were identified from a single-institutional database. A dysphagia score was obtained as part of the GERD health-related quality of life questionnaire. Persistent dysphagia was defined as a difficulty swallowing score ≥1 (noticeable) on a scale from 0 to 5 at least 1 y postoperatively. Odds ratios of persistent dysphagia among those who underwent antireflux surgery were calculated in a multivariate logistic regression model adjusted for fundoplication type, sex, age, body mass index, and redo operation.

RESULTS

Of the 441 patients who met inclusion criteria, 255 had ≥1 y of follow-up (57.8%). The median duration of follow-up was 3 y. In this cohort, 45.1% of patients underwent Nissen fundoplication and 54.9% underwent partial fundoplication. Persistent postoperative dysphagia was present in 25.9% (n = 66) of patients. On adjusted analysis, there was no statistically significant association between the type of fundoplication (Nissen versus partial) and the likelihood of postoperative dysphagia.

CONCLUSIONS

Persistent postoperative dysphagia after antireflux surgery occurred in approximately one-quarter of patients and did not differ by the type of fundoplication. These findings suggest that both Nissen and partial fundoplication are reasonable choices for an antireflux operation for properly selected patients.

Management of failure after surgery for gastro-esophageal reflux disease

Surgical treatment of gastro-esophageal reflux disease (ST-GERD) is well-codified and offers an alternative to long-term medical treatment with a better efficacy for short and long-term outcomes. However, failure of ST-GERD is observed in 2-20% of patients; management is challenging and not standardized. The aim of this study is to analyze the causes of failure and to provide a treatment algorithm. The clinical aspects of ST-GERD failure are variable including persistent reflux, dysphagia or permanent discomfort leading to an important degradation of the quality of life. A morphological and functional pre-therapeutic evaluation is necessary to: (i) determine whether the symptoms are due to recurrence of reflux or to an error in initial indication and (ii) to understand the cause of the failure. The most frequent causes of failure of ST-GERD include errors in the initial indication, which often only need medical treatment, and surgical technical errors, for which surgical redo surgery can be difficult. Multidisciplinary management is necessary in order to offer the best-adapted treatment.

Primary and Redo Antireflux Surgery: Outcomes and Lessons Learned

INTRODUCTION

Some patients require one or more reoperative interventions after undergoing primary antireflux surgery (ARS). We compared outcomes after primary and reoperative ARS.

METHODS

We queried a prospectively maintained database to identify patients who underwent ARS from September 23, 2003 to May 28, 2016. Patients were categorized into four groups: A (primary ARS), B (first reoperative ARS), C (second reoperative ARS), or D (≥ third reoperative ARS). Patients completed follow-up foregut symptom surveys and satisfaction questionnaires at regular intervals.

RESULTS

In total, 940 patients were studied (A: n = 545, B: n = 302, C: n = 80, D: n = 13). Age, sex, and BMI were comparable across groups. Heartburn was the most common preoperative symptom in A, whereas dysphagia was more common in B-D. Open approach, mean operative time, and mean blood loss increased from A to D (P < 0.05), as did need for Roux-en-Y reconstruction. Vagal injury (2-19-33-54%; P < 0.05), visceral perforation (2-20-36-23%; P < 0.05), postoperative leak (0.2-2-6-8%; P < 0.05 A vs. all), and morbidity (2-10-14-39%; P < 0.05) also increased from A to D. At mean follow-up of 36 months, the proportion of patients who reported no significant symptoms, excellent satisfaction, and likeliness to recommend this surgery to a friend progressively declined with each successive reintervention (P < 0.05).

CONCLUSIONS

Complications and patient-reported outcomes worsen with each reoperative ARS.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

High-resolution Manometry in Patients with Gastroesophageal Reflux Disease Before and After Fundoplication

Background/Aims

The study aimed to determine pre- and post-fundoplication esophagogastric junction (EGJ) pressure and esophageal peristalsis by high-resolution manometry (HRM) in patients with gastroesophageal reflux disease (GERD).

Methods

Pre-operative and post-operative HRM data from 25 patients with GERD were analyzed using ManoView version 2.0.1. with updated software for Chicago classification and pressure topography. The study involved swallowing water boluses of 10 mL in the upright position.

Results

Significant increase of mean basal EGJ pressure and minimal basal EGJ pressure was found in post-operative as compared with pre-operative patients (P < 0.05 and P < 0.001, respectively). Integrated relaxation pressure (IRP) reached higher values in post-operative patients than in pre-operative patients (P < 0.001). Intra-bolus pressure (IBP) was significantly higher (P < 0.05) and contractile front velocity (CFV) was slower (P < 0.01) in post-operative patients than in pre-operative patients. Moreover significant increase of distal contractile integral (DCI) was found in post-operative patients (P < 0.05). Hiatal hernia was detected by HRM in 11 pre-operative patients. Fifteen out of 25 post-operative patients complained of dysphagia.

Conclusions

Fundoplication restores the antireflux barrier by reinforcing EGJ basal pressures, repairing hiatal hernias, and enhances peristaltic function of the esophagus by increasing DCI. However slight IRP elevation found in post-fundoplication patients may result in bolus pressurization and motility disorders.

Pseudoachalasia secondary to bariatric surgery

Secondary achalasia may result from diseases that either infiltrate or compress the lower esophageal sphincter to create an increased high-pressure zone and subsequent esophageal body changes. With bariatric surgery, a potential high-pressure zone is created by a sleeve, band, or bypass just distal to the esophagus. We report four patients who years after a bariatric procedure developed dysphagia followed by esophageal body radiographic and/or manometric features of achalasia. In addition, each of these patients responded symptomatically to endoscopic or surgical therapy either which lowered this high-pressure zone. Furthermore, review of prior cases in the literature suggests this has occurred before. Physicians should be aware of this association but further study is needed on its true prevalence.

POSTFUNDOPLICATION DYSPHAGIA CAUSES SIMILAR WATER INGESTION DYNAMICS AS ACHALASIA

BACKGROUND

- After surgical treatment of gastroesophageal reflux disease dysphagia is a symptom in the majority of patients, with decrease in intensity over time. However, some patients may have persistent dysphagia.

OBJECTIVE

- The objective of this investigation was to evaluate the dynamics of water ingestion in patients with postfundoplication dysphagia compared with patients with dysphagia caused by achalasia, idiopathic or consequent to Chagas' disease, and controls.

METHODS

- Thirty-three patients with postfundoplication dysphagia, assessed more than one year after surgery, together with 50 patients with Chagas' disease, 27 patients with idiopathic achalasia and 88 controls were all evaluated by the water swallow test. They drunk, in triplicate, 50 mL of water without breaks while being precisely timed and the number of swallows counted. Also measured was: (a) inter-swallows interval - the time to complete the task, divided by the number of swallows during the task; (b) swallowing flow - volume drunk divided by the time taken; (c) volume of each swallow - volume drunk divided by the number of swallows.

RESULTS

- Patients with postfundoplication dysphagia, Chagas' disease and idiopathic achalasia took longer to ingest all the volume, had an increased number of swallows, an increase in interval between swallows, a decrease in swallowing flow and a decrease in water volume of each swallow compared with the controls. There was no difference between the three groups of patients. There was no correlation between postfundoplication time and the results.

CONCLUSION

- It was concluded that patients with postfundoplication dysphagia have similar water ingestion dynamics as patients with achalasia.

Progress in laparoscopic treatment of hiatal hernia

Hiatal hernia is a common disease whose incidence increases with age. It can be divided into four types: I, II, III and IV. Currently, laparoscopic treatment of hiatal hernia has become a new trend in surgical treatment, and laparoscopic hiatal hernia repair and laparoscopic fundoplication have become the main forms of surgery. In this paper, we review the progress in laparoscopic treatment of hernia hernia.

Evaluation and management of patients with symptoms after anti-reflux surgery

Over the past two decades, there has been an increase in the number of anti-reflux operations being performed. This is mostly due to the use of laparoscopic techniques, the increasing prevalence of gastroesophageal reflux disease (GERD) in the population, and the increasing unwillingness of patients to take acid suppressive medications for life. Laparoscopic fundoplication is now widely available in both academic and community hospitals, has a limited length of stay and postoperative recovery time, and is associated with excellent outcomes in carefully selected patients. Although the operation has low mortality and postoperative morbidity, it is associated with late postoperative complications, such as gas bloat syndrome, dysphagia, diarrhea, and recurrent GERD symptoms. This review summarizes the diagnostic evaluation and appropriate management of such postoperative complications. If a reoperation is needed, it should be performed by experienced foregut surgeons.

Identification of preoperative risk factors for persistent postoperative dysphagia after laparoscopic antireflux surgery

BACKGROUND

Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result.

AIM

This retrospective study evaluated the preoperative risk factors not surgery-related for persistent dysphagia after primary laparoscopic antireflux surgery.

METHODS

Patients who underwent laparoscopic antireflux surgery by the modified technique of Nissen were evaluated in the preoperative period retrospectively. Postoperative severity of dysphagia was evaluated prospectively using a stantardized scale. Dysphagia after six weeks were defined as persistent. Statistical tests of association and logistic regression were used to identify risk factors associated with persistent dysphagia.

RESULTS

A total of 55 patients underwent primary antireflux surgery by a single surgeon team. Of these, 25 patients had preoperative dysphagia (45,45%). Persistent postoperaive dysphagia was reported by 20 (36,36%). Ten patients (18,18%) required postoperative endoscopic dilatation for dysphagia. There was statistical association between satisfaction with surgery and postoperative dysphagia and requiring the use of antireflux medication after the procedure; and between preoperative dysphagia and postoperative dysphagia. Logistic regression identified significant preopertive dysphagia as risk factor for persistent postoperative dysphagia. No correlations were found with preoperative manometry.

CONCLUSIONS

Patients with significant preoperative dysphagia were more likely to report persistent postoperative dysphagia. This study confirms that the current manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for post-fundoplication dysphagia. Minucious review of the clinical history about the presence and intensity of preoperative dysphagia is important in the selection of candidates for antireflux surgery.

Dysphagia postfundoplication: more commonly hiatal outflow resistance than poor esophageal body motility

BACKGROUND

Historically, risk assessment for postfundoplication dysphagia has been focused on esophageal body motility, which has proven to be an unreliable prediction tool. Our aim was to determine factors responsible for persistent postoperative dysphagia.

METHODS

Fourteen postfundoplication patients with primary dysphagia were selected for focused study. Twenty-five asymptomatic post-Nissen patients and 17 unoperated subjects served as controls. Pre- and postoperative clinical and high-resolution manometry parameters were compared.

RESULTS

Thirteen of the 14 symptomatic patients (92.9%) had normal postoperative esophageal body function, determined manometrically. In contrast, 13 of 14 (92.9%) had evidence of esophageal outflow obstruction, 9 of 14 (64.3%) manometrically, and 4 of 14 (28.6%) on endoscopy/esophagram. Median gastroesophageal junction integrated relaxation pressure was significantly greater (16.2 mm Hg) in symptomatic than in asymptomatic post-Nissen patients (11.1 mm Hg, P = .05) or unoperated subjects (10.6 mm Hg, P = .02). Sixty-four percent (9/14) of symptomatic patients had an increased mean relaxation pressure. Dysphagia was present in 9 of 14 (64.3%) preoperatively, and elevated postoperative relaxation pressure was independently associated with dysphagia.

CONCLUSION

These data suggest that postoperative alterations in hiatal functional anatomy are the primary factors responsible for post-Nissen dysphagia. Impaired relaxation of the neo-high pressure zone, recognizable as an abnormal relaxation pressure, best discriminates patients with dysphagia from those without symptoms postfundoplication.

Impaired postoperative EGJ relaxation as a determinant of post laparoscopic fundoplication dysphagia: a study with high-resolution manometry before and after surgery

BACKGROUND

Laparoscopic fundoplication (FP) reduces gastroesophageal reflux (GER) efficiently. Dysphagia is its main complication, but no clear data have been published in literature to evaluate risk factors associated with it. The goal of this retrospective study was to identify factors associated with dysphagia occurring after FP for GER disease, with high-resolution manometry (HRM) performed before and after surgery.

METHODS

Twenty patients (11 women; mean age, 49 (range, 19-68 years) underwent HRM before and 2-3 months after laparoscopic Nissen-Rossetti FP. Analysis was performed with esophageal pressure topography according to the Chicago Classification.

RESULTS

Before FP, ten patients had a manometric hiatal hernia (none after FP). Esophagogastric junction (EGJ) pressures increased after surgery (p < 0.01). Bolus pressurization was present in 2% of all swallows before FP and in 22% after (p = 0.01). Postoperative bolus pressurization percentage was significantly correlated with EGJ relaxation as measured with integrated relaxation pressure (IRP) (r = 0.79, p < 0.01). Eight patients reported dysphagia after FP. The only pre- or post-operative parameter significantly associated with dysphagia was postoperative IRP (5.1 mmHg without vs. 10.3 with dysphagia, p < 0.02).

CONCLUSIONS

FP establishes an efficient antireflux mechanism by correcting hiatal hernia and increasing EGJ pressures. EGJ relaxation as measured by IRP is significantly altered after surgery, leading to more frequent motility disorders, and bolus pressurization. Postoperative dysphagia was associated with higher values of IRP.

Postoperative problems 2011: fundoplication and obesity surgery

Although the surgical treatment of both GERD and obesity is very successful, these procedures have a significant impact on the physiology and function of the proximal GI tract. With the increasing prevalence of both GERD and obesity, more and more patients present at the motility outpatient clinic with symptoms related to surgical interventions for these medical problems. In this review, we describe the main complications following antireflux surgery: dysphagia, gas bloat syndrome, recurrent (persistent) GERD symptoms, and dyspeptic symptoms. The most common motility-related complications of obesity surgery are dumping syndrome and esophageal dysmotility.