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Background: Roux-en-Y esophagojejunostomy (RYEJ) is an effective treatment option in some patients with complicated gastroesophageal reflux disease (GERD). Postoperative dysphagia is common, and is most often caused by mechanical problems such as stricture or bowel obstruction; however some patients develop refractory dysphagia in the absence of mechanical obstruction and do not respond to empiric dilation. The objective of this study was to evaluate the patients who underwent RYEJ and subsequently developed dysphagia, and assess the etiology of dysphagia.

Methods: This is a retrospective review of patients who had undergone RYEJ to treat GERD following prior upper gastrointestinal surgery. Prior to RYEJ, all patients underwent esophageal physiology testing including upper endoscopy, high-resolution manometry (HRM) and pH testing. Patients who developed postoperative dysphagia underwent both radiographic and endoscopic assessment to evaluate stricture formation and bowel obstruction, and subsequently underwent dilation (empiric or therapeutic). Patients who were un-responsive to dilation in the absence of mechanical obstruction, underwent HRM combined with antegrade impedance using both liquid and paste (pudding) to assess esophageal motility as a possible etiology of dysphagia.

Results: From July 2009 to July 2011, 13 patients underwent RYEJ, 10 of whom had prior surgery including Nissen fundoplication (n= 2), vertical banded gastroplasty (n=3), Heller myotomy with Dor fundoplication (n=1), gastric bypass (n=3) and Billroth II gastrectomy (n=1). Mean age and BMI were 55.3 years (range, 44-66 years) and 34.3 (range, 26.3-48.1), respectively. Eight of 13 (61.5%) patients developed dysphagia after RYEJ. No patients had radiographic evidence of small bowel obstruction. Upper endoscopy demonstrated anastomotic stricture (n=8) or roux limb narrowing within the transverse mesocolon (n=2), which was successfully treated with dilation. Three patients had incapacitating dysphagia with regurgitation in the absence of mechanical obstruction. HRM demonstrated esophageal primary peristaltic failure as evidenced by low mean wave amplitude ordered contractions and dropped peristaltic waves. All three patients had 100% incomplete bolus clearance with paste and this correlated with symptom of dysphagia. Two of three patients underwent esophagectomy with neck anastomosis and had complete symptom resolution.

Conclusion: For patients with non-obstructive, dilation refractory dysphagia following RYEJ, HRM combined with antegrade impedance testing using a defined liquid and paste protocol with symptom correlation is effective in determining etiology. Esophagectomy is an effective treatment option in this setting but long-term follow-up is required.