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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

DYSPHAGIA FOLLOWING A NISSEN-ROSSETTI FUNDOPLICATION: ENDOSCOPIC TREATMENT


F Jamali, MD, D Mutter, MD, PhD, S Vartolomei, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


Dysphagia is the most common complication following fundoplication. Distressing to patient and physician alike, the dysphagia often responds to conservative management. In case of failure of conservative management, operative intervention may be required.

2. Keywords


Nissen-Rossetti, fundoplication, dysphagia, antireflux

3. Patient


Female, 38-year-old

4. Past medical history


Fistula in 1997.

5. History of present illness


The patient presents with severe symptoms of heartburn and night coughing. The symptoms respond well to medical therapy with proton pump inhibitors but recur as soon as treatment is stopped.

6. Physical examination


Physical exam and screening laboratory values are normal.

7. Preoperative workup


Upper endoscopy:
- small hiatal hernia;
- stage I-II esophagitis.

8. Procedure


A laparoscopic fundoplication using the Nissen-Rossetti approach is performed as illustrated by this video.
video
Video 8

9. Postoperative course


The postoperative course is complicated by early dysphagia to solids.
Despite medical therapy, the dysphagia persists at the 4 and 8 weeks postoperative visits.

10. Workup


Contrast swallow:
- moderate esophageal dilatation;
- stenosis at the level of the Nissen wrap.

11. Clinical progression


The patient undergoes endoscopic pneumatic dilatation using a 30 mm balloon at 30 days postoperatively but the dysphagia persists.
A repeat dilatation using a 40 mm balloon is attempted at 2 months postoperatively.
Following 3 episodes of endoscopic pneumatic dilatation, the patient's dysphagia finally abates. Of note, the patient had not lost any weight since the operation.

12. Discussion


Postoperative dysphagia is the most common complication of current laparoscopic antireflux procedures. Immediate postoperative dysphagia is a common problem (affecting up to 50% of patients) but is usually self limited, resolving spontaneously at 3-6 weeks postoperatively. Persistent dysphagia is much more troublesome and debilitating and its true incidence is difficult to ascertain from the literature. Most large series report an incidence under 5% although numbers as high as 24% for grade I dysphagia have been quoted. An interesting study by Kamolz et al. (1999) emphasizes the subjective nature of the dysphagia problem and concluded that the degree of dysphagia and its resultant impairment as a result of laparoscopic antireflux surgery can be predicted according to the personal characteristics of the patient. Several studies have attempted to identify preoperative risk factors predictive of postoperative dysphagia among the classically performed preoperative tests (manometry, pH-monitoring, endoscopy, barium swallow). Hunt et al. (2000) evaluated the use of preoperative esophageal transit studies using a technetium-99m jello bolus (jello esophageal transit) as a useful predictor of dysphagia after fundoplication. They reported a sensitivity of 80% and a specificity of 95% in predicting a negative outcome. The management of dysphagia currently includes endoscopic dilatation which is effective in 60-80% of cases and can be repeated up to 3 times. In cases of refractory dysphagia a reoperation with a redo fundoplication or conversion to a partial one may be indicated.

13. References


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