Study on Postoperative Dysphagia Following Gastroesophageal Fundoplication and Response to Endoscopic Dilation

Ambar Banerjee, MD, Taylor Coleman, BS, Daniel McKenna, MD, Jennifer Choi, MD, Don Selzer, MD. Department of Surgery, Indiana University School of Medicine, Indianapolis, IN

Objective: The objective of our study was to assess –

• The incidence of dysphagia in patients who underwent complete or partial gastroesophageal fundoplication
• The effect of esophageal dilation on improvement of dysphagia and recurrence of reflux symptoms

Methods and procedures: Following institutional review board approval, retrospective chart review of patients who underwent partial/complete gastroesophageal fundoplication with/without paraesophageal hernia repair between January 2006 and January 2014 was performed from a prospective database. The patients’ charts were reviewed for information on demographics, preoperative work-up, postoperative follow-up and subsequent surgical interventions. The operative reports were reviewed to obtain perioperative data. Demographics and other baseline patient characteristics were analyzed with descriptive statistics. The significance of the relationships of the nominal and continuous variables was calculated with t-test or Chi-square test. P-values less than 0.05 were considered significant. Statistical analysis of the data was performed using the SPSS statistical software, version 20.0 (SPSS Inc., Chicago, IL).

Results: Nine hundred and two consecutive patients, with a mean age of 57.8±14.7 years were included in the study. Females comprised 71.3% of the population with an average BMI of 29.5±5.5 kg/m2. Laparoscopic Nissen fundoplication (NF) and laparoscopic paraesophageal hernia repair with NF were performed in 436 and 190 patients respectively. Laparoscopic Toupet fundoplication (TF) and laparoscopic paraesophageal hernia repair with TF was performed in 10 and 83 patients respectively.  22.9% of the patients presented for a revisional procedure. The mean operative time was 101.8±50.9 minutes with an average length of stay of 2.65±4.9 days. Postoperative dysphagia was noted in 26.3% patients. However, endoscopic dilation of the fundoplication was necessitated in 93 patients (10.3%) with persistence of dysphagia in 63.4% of this subpopulation (59 patients). (p<0.01) Occurrence of recurrent reflux symptoms was observed in 54.5% of the patients who underwent endoscopic dilation (p=0.27). Nissen fundoplication was performed in 89% of the patients with postoperative dysphagia while the rest had Toupet fundoplication. Dysphagia was more frequently noted in patients undergoing revisional surgery with complete fundoplication when compared with partial fundoplication. (p=0.81) The overall rate of subsequent revisional surgery was 35% in all patients who developed any postoperative dysphagia (p<0.01).

Conclusions: Endoscopic dilation of gastroesophageal fundoplication may provide some relief in patients complaining of postoperative dysphagia with increased risk of development of recurrent reflux. Revisional surgery may ultimately be indicated for control of symptoms.