DYSPHAGIA AFTER LAPAROSCOPIC TOTAL FUNDOPLICATION: anterior or posterior gastric wall fundoplication?

Abstract

-Context -The occurrence of severe dysphagia after laparoscopic total fundoplication is currently an important factor associated with loss of quality of life in patients undergoing this modality of treatment for gastroesophageal reflux disease. Objective -Compare the incidence and evaluate the causes of severe postoperative dysphagia in patients undergoing laparoscopic total fundoplication (LTF) without short gastric vessels division, using the anterior gastric wall (Rossetti LTF) or anterior and posterior gastric walls (Nissen LTF). Methods -Analysis of the data of 289 patients submitted to LTF without short gastric vessels division from January 2004 to January 2012, with a minimum follow-up of 6 months. Patients were divided in Group 1 (Rossetti LTF -n = 160) and Group 2 (Nissen LTF -n = 129). Results -The overall incidence of severe postoperative dysphagia was 3.11% (4.37% in group 1 and 1.55% in group 2; P = 0.169). The need for surgical treatment of dysphagia was 2.5% in group 1 and 0.78% in group 2 (P = 0.264). Distortions of the fundoplication were identified as possible causes of the dysphagia in all patients taken to redo fundoplication after Rossetti LTF. No wrap distortion was seen in redo fundoplication after Nissen LTF. Conclusion -The overall incidence of severe postoperative dysphagia did not differ on the reported techniques. Only Rossetti LTF was associated with structural distortion of the fundoplication that could justify the dysphagia.

Persistent dysphagia is a rare problem after laparoscopic Nissen fundoplication

“…So far, the LNF has been the standard anti-reflux surgery with proven long-term efficacy and safety as well as verified improvement in quality of life in patients undergone LNF [4, 5, 8, 9, 20]. Nevertheless, it is associated with several complications like PD and gas-bloat syndrome, potentially leading to further surgical interventions and patient dissatisfaction [3, 7–11, 20]. In an effort to decrease the gap between medical and surgical GERD therapy by reducing the risk of potential side effects, magnetic sphincter augmentation (MSA) as well as lower esophageal sphincter stimulation (LESS) have come to use.…”

“…Acknowledging the learning curve, technical standardization is a key step in achieving excellent results with low postoperative side-effect rates [11, 59]. …”

“…In our study, we observed only eight ( n = 8, 2%) patients with PD, which seems significantly lower than previously described in literature. Bonadiman et al reported a PD rate of 3.11% in a retrospective study comparing anterior and posterior gastric wall fundoplication, finding no significant difference between the groups [11]. Richter et al found 3–24% of patients developing PD after LNF [44].…”

“…One of the reasons behind a low surgery rate among GERD patients is the fear of its adverse effects [3, 4, 9]. Temporary side effects due to transient postoperative mucosal edema include dysphagia and increased bloating [7–11]. However, three to 24% of patients who underwent laparoscopic fundoplication continue to report persistent dysphagia (PD), making it one of the leading causes of procedure failure [7, 12, 13].…”

Predictive factors for short gastric vessels division during laparoscopic total fundoplication

“…Our results also showed more postoperative GERD symptoms. No benefit has been attributed to SGV division 15 . Very interestingly, however, authors that do not routinely divide SGV find this step necessary at the time of the fundoplication due to tension on the gastric fundus in up to 33% of patients 16 even after extensive gastric fundus mobilization by lysis of adhesions between the stomach and diaphragm 2,6 .…”