Tailored Antireflux Surgery for Gastroesophageal Reflux Disease: Effectiveness and Risk of Postoperative Dysphagia

Abstract

The Nissen fundoplication is not the proper antireflux procedure for patients with poor esophageal peristalsis as it does not strengthen impaired esophageal peristalsis. The aim of this study was to investigate if tailoring of antireflux surgery according to esophageal contractility is an effective treatment of gastroesophageal reflux disease (GERD) with a low incidence of postoperative dysphagia. The Toupet fundoplication was laparoscopically performed on 32 patients with poor esophageal peristalsis and the Nissen fundoplication on 17 patients with normal peristalsis. After a median follow-up of 15 months, only 1 of the 49 patients (2.04%) complained of heartburn. Acute esophagitis was found in none of them on endoscopy. Of 40 patients tested postoperatively, 2 (5%) underwent pathologic esophageal pH monitoring. Postoperative dysphagia was found in two patients (4.1%) compared with 25 (51%) preoperatively (p < 0.05). There was a significant reduction of dysphagia following the Toupet fundoplication. Both procedures increased the resting pressure of the lower esophageal sphincter (LES) significantly, which was more pronounced following the Nissen fundoplication. Relaxation of the LES was significantly better following the Toupet than after the Nissen fundoplication. There was significant improvement of esophageal peristalsis following the Toupet fundoplication. Tailored antireflux surgery is an effective strategy for treatment of GERD. The incidence of postoperative dysphagia is low owing to improvement of impaired esophageal peristalsis following the Toupet fundoplication. It may be due to the fact that the Toupet fundoplication causes less esophageal outflow resistance than the Nissen fundoplication.

Laparoskopische Toupet-Fundoplicatio bei Patienten mit gastroösophagealer Refluxkrankheit und gestörter Ösophagusperistaltik

“…Der durch die NissenFundoplicatio erzeugte relativ hohe Ruhedruck und die damit verbundene zusätzliche Verschlechterung der Ösophagus-Clearance könnten dafür verantwortlich sein [7,9]. Die Steigerung des Ruhedrucks durch die Toupet-Fundoplicatio ist geringer [6,11,14,20]. Die erzielte intraabdominale Sphinkterlänge entspricht in etwa jener der Nissen-Fundoplicatio; die Sphinkterrelaxierung hingegen entspricht nach Toupet-Fundoplicatio mehr dem physiologischen Normalzustand [14].…”

“…Die Steigerung des Ruhedrucks durch die Toupet-Fundoplicatio ist geringer [6,11,14,20]. Die erzielte intraabdominale Sphinkterlänge entspricht in etwa jener der Nissen-Fundoplicatio; die Sphinkterrelaxierung hingegen entspricht nach Toupet-Fundoplicatio mehr dem physiologischen Normalzustand [14]. Dadurch wird der Ösophagusperistaltik ein geringerer Ausgangswiderstand entgegengesetzt und der Transport des Nahrungsbolus durch den Sphinkter auch bei eingeschränkter Motilität erlaubt.…”

“…Diese Kohortenstudie untersucht die mittelfristigen bis Langzeitergebnisse nach Toupet-Fundoplicatio bei Refluxpatienten mit gestörter Öso-phagusperistaltik hinsichtlich des Wiederauftretens der Refluxsymptome, der Dysphagie, des endoskopischen Befunds sowie der funktionellen Diagnostik. [14]. …”

Selection of Patients for Laparoscopic Antireflux Surgery

“…These patients will require a looser wrap or a partial fundoplication to sideration for surgery. Although the diagnosis of bile reflux may be difficult to establish, DGR is associated with prevent persistent postoperative dysphagia [71]. Preoperative motility studies also aid in the identification of the an increased risk of carcinoma [76,79].…”

The effect of narrowed segment length on the degree of early postoperative dysphagia in laparoscopic Nissen fundoplication

“…It has a 96% success rate in the treatment of GERD symptoms (3). One of the most troublesome complications of LNF is persistent dysphagia postoperatively (4). It is more prominent in the early postoperative period.…”