Post-Nissen Dysphagia and Bloating Syndrome: Outcomes after Conversion to Toupet Fundoplication.

Katrin Schwameis, MD, Joerg Zehetner, MD, Steven R DeMeester, MD, Nikolai Bildzukewicz, MD, Daniel Oh, MD, Geoffrey Ro, Ross Katherine, Kulmeet K Sandhu, MD, Namir Katkhouda, MD, Jeffrey A Hagen, MD, John C Lipham, MD. Keck hospital, USC

Introduction. Protracted dysphagia and bloating are potential troublesome complications following Nissen fundoplication. One treatment option is a redo-fundoplication with conversion to a Toupet (CNT), but outcomes after this are poorly defined. The aim of this study was to evaluate the effects of CNT on dysphagia/bloating and GERD symptoms.

Methods. Retrospective data collection and analysis including a standardized foregut questionnaire and GERD-HRQL were performed for patients who had undergone CNT for the treatment of post-Nissen dysphagia or bloating syndrome between 2001 and 2014. Patients with hiatal hernia recurrence or slipped/disrupted Nissen were excluded.

Results. Twenty-five patients (16 males, 9 females) underwent CNT after a mean time of 5.9 years (0.5-15.8) at a mean age of 58 (20-84) years. Indications for CNT were: A) persistent dysphagia (n=16, 64%), B) combined dysphagia/bloating (n=1, 4%), C) dysphagia/reflux (n=3, 12%) and D) bloating syndrome (n=5, 20%). Ineffective treatment attempts prior to CNT included Botox injections, dilations and Redo-fundoplication (n=2 vs. n=14 vs. n=1). Manometry and videoesophagram examinations performed before conversion found esophageal motility abnormalities in 52% (n=13) of patients.

CNT was accomplished laparoscopically in 92% of cases.  The mean OR time was 114.4 min (53-224). No mortality or serious complications occurred. Mean follow-up time was 26.7 months (0.8 – 130). Postoperative relief of the primary symptom occurred in 87%, 100% and 100%/67%, respectively, for dysphagia, bloating and combined dysphagia/reflux. Further re-interventions were required in four patients. The GERD-HRQL was obtained in 88% (n=22) of patients post-CNT and showed a mean score of 10.1 (0-45).

Conclusions. Conversion of Nissen to Toupet fundoplication in the treatment of postoperative dysphagia or bloating relieved symptoms in 87-100% of patients without leading to significant GERD recurrence. Given the absence of serious complications conversion should be considered earlier in patients with severe ongoing bloating or dysphagia.

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