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Laparoscopic Nissen Fundoplication Significantly Decreases Gastroesophageal Junction Distensibility
Dennis Blom, Shailesh Bajaj, Jianxing Liu, Osamu Kawamura, Candy Hofmann, Tanya Rittmann, Ronald Arndorfer, Gary Korus, Thomas Derksen, Reza Shaker, Medical College of Wisconsin, Milwaukee, WI
Introduction: Laparoscopic Nissen fundoplication (LNF) is the surgical treatment of choice for GERD. Post-LNF complications, such as dysphagia, remain too common and prevent LNF from being more highly accepted and recommended. It is controversial as to whether preoperative assessment can predict the development of post-LNF complications. Some authors have shown correlation between post-LNF dysphagia and pre-LNF manometry characteristics, while others have not. We hypothesize that many post-LNF complications and particularly dysphagia is caused by a decrease in the distensibility of the GEJ and that standard manometry is at best an indirect measure of this. The aim of this study is to directly measure the effect of LNF on gastroesophageal junction (GEJ) distensibility (GEJD).
Methods: The gastroesophageal junction of ten patients undergoing LNF was characterized using standard manometry. The GEJD before and after a standardized LNF was measured using a specialized catheter, containing an infinitely compliant bag, placed within the GEJ. GEJD was measured, as dP/dV over volumes 5-25 ml distended at a rate of 20 ml/min. Mean dP ± SEM for each volume was calculated and distensibility curves were generated and compared. Measurements were also taken after abolishing lower esophageal sphincter (LES) tone by mid-esophageal balloon distension. Patient symptoms were recorded before and after surgery. Statistical analysis was performed by two-way ANOVA repeated measures. Results: There were no complications related to GEJD measurement or surgery and no patient developed the symptom of dysphagia postoperatively. Laparoscopic Nissen fundoplication led to a statistically significant increase in Dpressure over each volume tested (dP/dV) and therefore a significant decrease in the distensibility of the GEJ. Abolition of LES tone had no statistical effect on GEJD in these anesthetized patients.. Conclusions: These are the first direct measurements to show that LNF significantly reduces the distensibility of the GEJ. We believe the magnitude of this reduction may be the vital variable in the development of post-LNF complications and specifically post-LNF dysphagia. The intraoperative measurement of LES distensibility may provide a means for avoiding this feared and other post-LNF complications in the future.
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