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 25 November 2017

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News

Dysphagia a problem of hiatal closure after surgery

In most patients, postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap, finds the latest issue of Surgical Endoscopy.

News image

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Postoperative dysphagia after laparoscopic antireflux surgery usually is transient and resolves within weeks after surgery.

Persistent dysphagia develops in a small percentage of patients after surgery.

There still is debate about whether postoperative dysphagia is caused by the type or placement of the fundic wrap or by mechanical obstruction of the hiatal crura.

Dr Granderath and colleagues investigated patients who experienced recurrent or persistent dysphagia after laparoscopic antireflux surgery.

The research team identified the morphologic reason for this complication.

A sample of 50 patients consecutively were referred to the researchers' unit.

The patients presented with recurrent, persistent, or new-onset of dysphagia after laparoscopic antireflux surgery.

10% of all 50 patients in Group 3 presented with the symptom of dysphagia
Surgical Endoscopy

The researchers prospectively reviewed the patients to identify the morphologic cause of postoperative dysphagia.

According to their radiologic findings, these patients were divided into 3 groups.

Group 1 included 18 patients with signs of obstruction at or above the gastroesophageal junction suspicious of crural stenosis.

There were 27 patients in Group 2 with signs of total or partial migration of the wrap intrathoracically.

The team included 5 patients in Group 3 in whom the hiatal closure was radiologically assessed to be correct with a supposed stenosis of the wrap.

The exact diagnosis of a too tight hiatus, as in Group 1, was established during by x-ray during pneumatic dilation.

The researchers diagnosed a too loose hiatus in Group 2 was established during laparoscopic redo surgery.

A too tight wrap in Group 3 was established during laparoscopic redo surgery.

For all 18 Group 1 patients, intraoperative x-ray during pneumatic dilation showed the typical signs of hiatal tightness.

Of these, the team noted that 15 were free of symptoms after dilation, and 3 had to undergo laparoscopic redo surgery because of persistent dysphagia.

In all these patients, the hiatal closure was narrowing the esophagus.

The team reported that all the Group 2 patients underwent laparoscopic redo surgery because of intrathoracic wrap migration.

Intraoperatively, all the patients had an intact fundoplication, which slipped above the diaphragm.

The team observed that in 10% of all 50 patients in Group 3 presented with the symptom of dysphagia.

In addition, the researchers noted that this was the morphologic reason for the obstruction a problem of the fundic wrap.

Dr Granderath's team concluded, “In most patients, postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap.”

Surg Endoscopy 2005: 19(11): 1439-46
21 November 2005

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