Websurg, e-Surgery 關於腹腔鏡手術

Clinical Case

DYSPHAGIA FOLLOWING A NISSEN-ROSSETTI FUNDOPLICATION: SURGICAL THERAPY

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

1. Description

Dysphagia, albeit often transient, is the most common complication of fundoplication. Persistent dysphagia is a distressing complication to patient and physicians alike. This case illustrates a case of dysphagia following a Nissen-Rossetti fundoplication that failed to respond to conservative management and required operative reintervention.

2. Key words

Nissen-Rossetti, dysphagia, Toupet fundoplication, partial fundoplication, redo antireflux surgery

3. Patient

Female, 50-year-old

4. Past medical history

Hypercholesterolemia, medically treated.

5. History of present illness

5 months prior to his current presentation, the patient had undergone a laparoscopic Nissen fundoplication for symptomatic gastroesophageal reflux disease. This was complicated by the onset of dysphagia in the immediate postoperative period. The dysphagia was severe to both solids and liquids.

6. Contrast swallow

Filiform passage of contrast at the gastroesophageal junction.
Dilated esophagus with retention of contrast and food debris.

Figure 6.a

Figure 6.b

Figure 6.c

Figure 6.d

Figure 6.e

7. Upper endoscopy

Large amounts of food debris in a dilated esophagus.
Relatively easy passage of the scope into the stomach.
Retroversion in the stomach reveals a "corkscrew" appearance to the gastric folds at the level of the G-E junction suggestive of a twist.

8. Clinical progression

Over the next 3 months, the patient undergoes 6 pneumatic dilatations to no avail. The dysphagia is only temporarily relieved and recurs 3-4 days after each dilatation. During the last dilatation, a tight stricture at the level of the G-E junction is visualized.

Figure 8.a

Figure 8.b

Figure 8.c

9. Surgical therapy

The patient is then referred for redo surgery. He has lost 10 kg over the last 6 months. Upon laparoscopic exploration, a tight fibrous band at the level of the distal esophagus as well as a "twist" of the wrap are noted.
The wrap is taken down and converted to a Toupet partial fundoplication. The fibrous adhesions encasing the distal esophagus are released.

10. Video

This video illustrates briefly the surgical procedure performed.
After laparoscopic exploration and release of adhesions, a tight band is noted at the level of the gastroesophageal junction, which is divided.
The Nissen wrap is converted to a Toupet partial fundoplication.
video

Video 10

11. Postoperative contrast swallow

Easy passage of contrast is noted at the level of the gastroesophageal junction.

Figure 11.a

Figure 11.b

Figure 11.c

Figure 11.d

12. Clinical follow-up

The patient is doing well with no dysphagia and no reflux symptoms at 1 and 3 months postoperatively.

13. 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. (2000) 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. (1999) 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.

14. References

Baigrie RJ, Watson DI, Myers JC, Jamieson GG. Outcome of laparoscopic Nissen fundoplication in patients with disordered preoperative peristalsis. Gut 1997;3:381-5.
Dallemagne B, Weerts JM, Jeahes C, Markiewicz S. Results of laparoscopic Nissen fundoplication. Hepatogastroenterology 1998;23:1338-43.
Frantzides CT, Richards C. A study of 362 consecutive laparoscopic Nissen fundoplications. Surgery 1998;4:651-5.
Gotley DC, Smithers BM, Menzies B, Branicki FJ. Laparoscopic Nissen fundoplication and postoperative dysphagia-can it be predicted? Ann Acad Med Singapore 1996;5:646-9.
Herron DM, Swanstrom LL, Ramzi N, Hansen PD. Factors predictive of dysphagia after laparoscopic Nissen fundoplication. Surg Endosc 1999;12:1180-3.
Hunt DR, Humphreys KA, Janssen J, Mackay E, Smart R. Preoperative esophageal transit studies are a useful predictor of dysphagia after fundoplication. J Gastrointest Surg 1999;5:489-495.
Hunter JG, Swanstrom L, Waring JP. Dysphagia after laparoscopic antireflux surgery. The impact of operative technique. Ann Surg 1996;1:51-7.
Kamolz T, Bammer T, Pointner R. Predictability of dysphagia after laparoscopic Nissen fundoplication. Am J Gastroenterol 2000;2:408-14.
Kozarek RA, Low DE, Raltz SL. Complications associated with laparoscopic anti-reflux surgery: one multispecialty clinic's experience. Gastrointest Endosc 1997;6:527-31.

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