Clinical features and oesophageal motility in patients with tight fundoplication

Objective: Tight fundoplication is a well known complication of surgery for gastroesophageal reflux. We have noted, in clinical experience, that some patients operated for gastro-oesophageal reflux develop pharyngo-oesophagea l dysphagia. This study was undertaken to elucidate, by comparing motility data in patients with and without tight fundoplication, the pathophysiologi c characteristics of the swallowing mechanism and to clarify the cause of d ysphagia in these patients. Methods: Sixteen patients with postoperative pe rsistent dysphagia following a fundoplication have been studied, of those 1 0 presented a lower oesophageal sphincter resting pressure above or equal t o 30 mmHg (group A). Clinical work-up included a questionnaire, oendoscopy, manometry and barium meal or video-roentgenography. Oesophageal manometry was performed using a slow pull through technique while the stationary pull through technique was used for the pharyngo-oesophageal segment. The follo wing parameters were evaluated: (a) amplitude of pharyngeal contraction; (b ) upper oesophageal sphincter resting pressure; (c) amplitude of upper oeso phageal sphincter contraction; (d) amplitude of oesophageal contraction; (e ) lower oesophageal sphincter resting pressure. The results were compared t o those of 21 patients who had a fundoplication with normal lower oesophage al sphincter pressure (group B). Results: in group A there were three males and seven females, with a mean age of 51 years (ranging from 28 to 60 year s). Previous operations were Nissen in two and Nissen Rossetti in eight pat ients. Three out of 10 patients of group A presented pharyngo-oesophageal d ysphagia. Mean lower oesophageal sphincter 36 versus 21 mmHg and upper oeso phageal sphincter 86 versus 42 mmHg resting pressure, pharyngeal 147 versus 76 mmHg and oesophageal amplitude, upper oesophageal contraction 251 versu s 103 mmHg were significantly higher in patients of group A versus group B. An increased number of repetitive contractions was also found in group A. The presence of a strong correlation was demonstrated between the pharyngea l amplitude and the closing tone of the upper oesophageal sphincter (R2 0.7 42 and R2 0.739) in both groups. Conclusion: Tight fundoplication is, in ou r experience, always associated with total fundoplication. The appearance o f pharyngo-oesophageal dysphagia in the postoperative period in patients op erated on to correct gastroesophageal reflux using a total fundoplication, should not be under-estimated because it suggests an obstruction of the dis tal oesophagus. (C) 1999 Elsevier Science B.V. All rights reserved.