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Dysphagia After Nissen Fundoplication - Is Preoperative Esophageal Motility a Factor?
Anna Aronova*, Kayvon Sharif, Brendan M. Finnerty, Rasa Zarnegar, Cheguevara Afaneh, Thomas J. Fahey, Thomas Ciecierega, Carl V. Crawford
Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
Background - There is controversy over the incidence of dysphagia after Nissen fundoplication, especially in patients with abnormal preoperative esophageal motility. As such, some clinicians recommend partial wraps in this subgroup. We aimed to assess the relationship between preoperative esophageal dysmotility and the degree and duration of dysphagia after laparoscopic and robot-assisted Nissen fundoplication.
Methods - A retrospective review was performed on all consecutive patients who underwent laparoscopic and robot-assisted Nissen fundoplication at a single center between 2009 and 2014. We excluded patients undergoing re-operative fundoplication, as well as those with a primary motility disorder. Preoperative factors examined included: demographics, symptoms, DeMeester scores, and duration of acid suppression therapy. Analyzed outcomes included postoperative symptom resolution and duration of dysphagia, as self-reported by patients at their two-week and three-month visits. Patients were classified as having normal or abnormal preoperative motility based on the results of high-resolution esophageal manometry. Postoperative dysphagia was graded in accordance with the Chicago classification criteria.
Results - Eighty-two patients met inclusion criteria. No significant preoperative differences were found between normal (n=48) and abnormal (n=34) motility groups including age, DeMeester scores, and duration of acid suppression therapy. All patients experienced dysphagia at 2 weeks, but the mean Chicago classification dysphagia scores between patients with normal and abnormal preoperative motility did not differ [1.89±0.56 vs. 2±0.65, respectively, p=0.62]. At 3 months, 8.7% and 24% of patients with normal and abnormal preoperative motility, respectively, experienced dysphagia (p=0.11). Per patient, the Chicago Classification scores improved significantly more for the normal preoperative motility group (0.11±0.38) compared to the abnormal motility group (0.24±0.44), p<0.01. However, all patients with abnormal preoperative motility who experienced dysphagia at 3 months postoperatively reported full resolution of dysphagia within 18 months. Lastly, rates of dysphagia did not differ between laparoscopic (n=26) or robotic (n=56) approaches at 2 weeks (p=0.81) or 3 months (p=0.67).
Conclusions -Some degree of dysphagia is to be expected postoperatively regardless of preoperative esophageal motility status; however patients with normal preoperative esophageal motility have a more pronounced improvement in dysphagia at three months. As such, clinicians should counsel patients accordingly prior to Nissen fundoplication surgery.
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