2005 Abstracts: Laparoscopic Nissen Fundoplication in Patients with Severe Esophageal Dysmotility
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Laparoscopic Nissen Fundoplication in Patients with Severe Esophageal Dysmotility
Yuri W. Novitsky, Carolinas Medical Center, Charlotte, NC; Gordie K. Kaban, University of Massachusetts Medical Center, Worcester, MA; Andrew G. Harrell, Michael J. Rosen, Timothy S. Kuwada, Carolinas Medical Center, Charlotte, NC; Kent W. Kercher, Carolinas Medical Center, c, NC; Demetrius E. Litwin, University of Massachusetts, Worcester, MA; B. T. Heniford, Carolinas Medical Center, Charlotte, ND
Background: Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease. In patients with esophageal dysmotility a less effective partial fundoplication has been advocated to avoid postoperative dysphagia. Although LNF is known to be superior to partial wrap in patients with weak peristalsis, its efficacy in patients with severe dysmotility is unknown. We hypothesized that a 360° fundoplication is preferable in patients with severe esophageal dysmotility.
Methods: Multicenter retrospective review of consecutive patients with severe esophageal dysmotility (distal esophageal amplitude [DEA] of ≤30 mmHg and/or ≥60% of non-peristaltic esophageal body contractions [EBC]) who underwent a LNF at a tertiary care hospital. Variables measured included patient demographics, preoperative signs and symptoms, preoperative esophageal manometry and 24-hr pH studies, postoperative dysphagia, gas bloat, and reflux recurrence. Results: Eighteen patients (7 men and 11 women) with severe esophageal dysmotility who underwent LNF at a tertiary care hospital were reviewed. All patients presented with symptoms of GERD, including dysphagia in 4 (22%) patients. Seven patients had an impaired EBC, 7 patients had an abnormal DEA, and 4 patients had both. Average abnormal DEA was 25.1 ± 3.2 mmHg (range, 19.3-30.0 mmHg). The mean number of non-peristaltic EBC was 69.4 ± 8.2% (range, 60.0%-83.0%). At operation, all short gastric vessels were divided, the crura were reapproximated, and a loose short 360-degree fundoplication was performed. There were no intra-operative complications and no conversions. Postoperatively, early dysphagia occurred in 11 (61%) patients. Early dysphagia resolved in 10 of 11 patients between 2 and 8 weeks postoperatively. At an average follow up of 12.4 months (range, 1-26 months) 1 patient was found to have mild persistent dysphagia controlled with dietary modifications. Symptoms of gas bloat persisting for more than 1 month were noted in 3 (15%) patients. These symptoms have resolved in all patients by 12 weeks. One patient required daily medication for mild persistent reflux symptoms. Conclusion: LNF provides low rates of reflux recurrence without significant long-term postoperative dysphagia in patients with severely disordered esophageal peristalsis. Thus, a 360° fundoplication may be the preferred anti-reflux procedure in patients with severe esophageal dysmotility.
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