Analysis and surgical treatment of persistent dysphagia after Nissen fundoplication

Background: After Nissen fundoplication, troublesome dysphagia develops in 5-10 per cent of patients. The mechanism of dysphagia has not been fully re solved, in spite of a number of studies focusing on oesophageal motility an d lower oesophageal sphincter (LOS) dynamics. Tightness and length of the w rap have had considerable attention, without giving a fully satisfactory ex planation of the pathophysiological mechanism. Methods: Eighteen patients with persistent dysphagia after Nissen fundoplic ation needing reoperation were studied. Eighteen patients, matched for age and sex, without dysphagia after Nissen fundoplication were used as control s. Reoperation consisted of conversion of a 360 degrees into a 270 degrees wrap, Barium swallow, endoscopy, oesophageal manometry and 24-h pH monitori ng were performed before and after (re)operation, Results: Peristaltic amplitude, velocity and duration of contraction were n ot significantly influenced by operation. In 16 of 18 patients with dysphag ia, LOS relaxation was incomplete and the residual relaxation pressure was significantly higher than that in the group without dysphagia (P < 0.01). N o correlation was found between LOS pressure and peristaltic amplitude, nor between LOS pressure and ramp pressure in the distal oesophagus. After reo peration, basal LOS pressure decreased significantly (P < 0.01) and LOS rel axation was complete in ail but three patients; residual relaxation pressur e decreased (P < 0.01) and was significantly lower than that after uncompli cated Nissen fundoplication. In the latter group, LOS pressure, residual re laxation pressure and ramp pressure increased significantly after operation (P < 0.01). Conclusion: A return to complete LOS relaxation and a decrease in residual relaxation pressure play an important role in resolving dysphagia.