DYSPHAGIA AFTER LAPAROSCOPIC ANTIREFLUX SURGERY - THE IMPACT OF OPERATIVE TECHNIQUE

Background Concerns about laparoscopic antireflux surgery include the frequent appearance of troublesome postoperative dysphagia. This study reviews the frequency of early (less than 6 weeks) and persistent (gr eater than 6 weeks) solid food dysphagia in patients undergoing Toupet , Rosetti-Nissen, or Nissen fundoplications. Methods One hundred eight y-four consecutive patients with normal esophageal peristalsis undergo ing laparoscopic antireflux surgery were prospectively studied. Before operation, all patients had endoscopy, 24-hour pH study, and an esoph ageal motility study. The choice of operation was dependent on anatomy and surgeon preference. Before discharge, all patients were given ins tructions on a soft diet. Postoperative symptoms were scored by the pa tients as absent, mild, moderate, or severe 4 weeks and 12 weeks after operation. The option of esophageal dilation was offered to patients with moderate to severe persistent solid food dysphagia. Results New o nset moderate to severe dysphagia to solid foods was present in 30 (54 %), 8 (17%), and 13 (16%) patients undergoing Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively, in the first month after ope ration (p < 0.001). Moderate to severe dysphagia persisted at 3 months in six (11%), one (2%), and two (2%) patients undergoing laparoscopic Rosetti-Hell, Nissen, and Toupet fundoplications, respectively (p < 0 .05). Esophageal dilatation was performed in five (4%), zero, and one (1%) patients undergoing laparoscopic Rosetti-Nissen, Nissen, and Toup et fundoplications, respectively (p < 0.05). There was no additional m orbidity related to division of short gastric vessels in patients unde rgoing Nissen fundoplication. Conclusions Laparoscopic Rosetti-Nissen fundoplication is associated with a higher rate of early and persisten t postoperative dysphagia than either laparoscopic Nissen fundoplicati on or Toupet fundoplication. Consideration of complete fundus mobiliza tion should be a part of all laparoscopic antireflux procedures.