Severe dysphagia after laparoscopic fundoplication: Usefulness of barium meal examination to identify causes other than tight fundoplication - a prospective study

Background. The aim of this study was to determine the results of a barium meal examination after laparoscopic wrap in symptomatic patients (SPs) with no upper endoscopic anomalies and no increase in inferior esophageal sphin cter pressure (SPs). Radiologic results were compared with results from pat ients with no symptoms (ASPs) and were compared with the surgical findings in patients who underwent reoperation. Methods. Twenty SPs were included 27 +/- 6 months after a total wrap (n = 1 3 Nissen procedures) or a posterior wrap (n = 7 Toupet procedures) performe d in several hospitals in Haute Normandie. All patients had severe symptoma tic dysphagia with epigastric pain (n = 18 patients) and/or marked weight l oss (n = 16 patients). Control subjects were 31 consecutive ASPs within our center who were prospectively included 4 +/- I months after a Nissen (n = 6 patients) or a Toupet (n = 25 patients) procedure. A barium meal examinat ion was performed in all patients and interpreted by 3 independent observer s who knew that the patients had undergone a wrap but who did not know whet her the patients had symptoms. Fifteen of the 20 SPs underwent a second ope ration. Results. Barium meal examination was more often abnormal in SPs than in ASP s (17/20 vs 4/31 patients; P < .001), whichever the type of wrap. Two abnor mal radiologic results were observed in both groups: an esophageal barium l evel and an esogastric plication. Only a high barium level in the esophagus was more frequently observed in SPs than in ASPs (P < .05). Three radiolog ic results were specifically observed in SPs: a long cardial narrowing begi nning above the wrap, a mediogastric plication, and a gastric volvulus. A c omparison of radiologic anomalies and surgical findings showed that (1) a r adiologic long cardial narrowing was explained by fibrotic stenosis of the muscular esophageal hiatus (n = 6 patients), (2) a mediogastric plication ( n = 4 patients) was due to gastric volvulus (n = 3 patient) or to gastric w rap (n = 1 patient), and (3) results of volvulus (n = 5 patients) indicated a gastric volvulus. Additional surgical procedures resulted in the disappe arance of symptoms in 13 of 15 patients. Conclusions. After laparoscopic fundoplication when upper endoscopy and eso phageal manometry are normal, results of a barium meal examination can expl ain the cause of dysphagia in almost all patients. Three radiologic results were specific for SPs and indicated major morphologic disturbances that co uld not be treated by endoscopic dilation but that could be treated by addi tional surgical procedures.