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Esophageal stenting for fundoplications: is it necessary?
P Hansen, B Jobe, B Standage, L Swanstrom.
Legacy Portland Hospital, Portland, OR.

Introduction: The use of a large esophageal stent to guage the tightness of a Nissen fundoplication has been widely accepted as dogma with very little scientific verification. We present the results of a randomized prospective study on laparoscopic Nissens with or without the use of an esophageal stent to determine the incidence of bougie related complications and the relative incidence and severity of post operative dysphagia.

Methods: Patients scheduled for an elective antireflux surgery at one institution were randomly assigned to one of two groups. Group I had a standard laparoscopic Nissen with a large esophageal bougie (56 Fr). Group II had exactally the same repair with no bougie. Patients with giant paraesophogeal hernias, Collis lengthening procedures or partial fundoplications (done for motility disorders) were excluded from this analysis. Complications related to bougie use were recorded. Dysphagia was assessed according to a frequency and severety score preop, immediately postop (< 4 weeks) and for long term (>4 weeks). Results were tabulated and subjected to a student - T test for statistical validity.

Results: Between 3/96 and 12/96 88 laparoscopic antireflux surgeries were randomized to the study. 38 met the criteria of simple, uncomplicated Nissen fundoplications and were analyzed for this study. Data was collected in a blinded fasion. There were 20 patiens in the no stent group and 18 in the stented group. The incidence of bougie injuries in group I was 5%(I pharyngeal laceration). Preoperative dysphagia was present in 40% of group I and 67% of group II. Early postop dysphagia was noted in 84% of group I and 62% of group II. Late dysphagia was described in 47% and 36% respectedly for group I and II. No patients in either group have recieved intervention for their dysphagia. The mean dysphagia score for group I for the three time frames was 3.4, 10.5, 1.9 respectively. For group II the scores were 7.1, 4.2, 1.9. These differences were significant for the early postop group (p=.03) but not for the preop score (p=.13) or for the late post op period (p=.93).

Conclusion: We present the first randomized prospective study that attempts to validate the use of esophageal stenting in Nissen fundoplication and show that there is, infact, a higher incidence of transient dysphagia in patients when a bougie is not used. On the other hand, long term dysphagia rates were not different. The avoidence of early dysphagia must be balanced against an incidence of bougie related injuries (5%) during the laparoscopic procedure. Based on these results we feel that the routine use of an esophageal stent during a laparoscopic fundoplication is not indicated.