Patients with Dysphagia

The evaluation of new or recurrent symptoms depends on the timing after surgery. Postoperative dysphagia within 3 months of surgery is fairly common and occurs in up to 30–40% of cases: the etiology is often multifactorial [7]. Esophageal and fundoplication edema, transient esophageal dysmotility, and hematomas due to needle injury can all cause temporary gastroesophageal junction outflow obstruction. As a general rule, dysphagia in this setting can be managed conservatively unless there is concomitant dehydration, weight loss, bleeding, or persistent vomiting. Because we anticipate some degree of dysphagia in all our patients, we recommend that all adhere to a liquid diet for 2 weeks postoperatively, followed by a soft diet for 2 weeks, avoiding raw vegetables, hard meats, and breads that may worsen postoperative dysphagia or precipitate food impaction or retching.

Beyond the early postoperative period, dysphagia occurs in 2–5% of cases up to 5 years after surgery [8, 9]. Causes of postoperative dysphagia can be divided into distinct categories. Fundoplication issues include overly tight wrap, twisted wrap, slipped, or malpositioned fundoplication. Another category is that of a normal fundoplication with tight or constricted hiatal closure. Undiagnosed esophageal motility disorders such as achalasia, ineffective esophageal motility, and eosinophilic esophagitis may also cause evolving dysphagia. Finally, recurrent paraesophageal hernias in the setting of a prior repair with full or partial fundoplication may manifest as dysphagia [8–11]. A solid predictor of postoperative dysphagia is preoperative dysphagia [12]. Interestingly, preoperative motility studies can be of poor predictive value [13].

Workup and Treatment

When liquids are not tolerated after 6–12 weeks postoperatively, we recommend evaluation with a barium esophagram that includes ingestion of a 13-mm barium pill (or “tablet” as it is also termed). This study will identify any major anatomic abnormalities as well as stenosis at the gastroesophageal junction if the barium pill fails to pass after more than 30 seconds. If the esophagram shows normal passage of both contrast and the barium pill, then a functional problem most likely exists. In these instances, if symptoms are mild to moderate, then reassurance can be provided. It has been our experience that reassurance alone (in conjunction with a thorough dietary history and counselling) can resolve dysphagia in approximately 40% of cases without any further interventions. In all cases, however, plans should be made for an esophageal motility study if symptoms do not resolve within 2–4 weeks from consultation. Overall, the current literature suggests that 50% of patients with mild dysphagia without weight loss and few dietary restrictions will resolve their symptoms within a year [14, 15]. In instances when stenosis is demonstrated at the gastroesophageal junction by no (or delayed) passage of the barium pill, endoscopic balloon dilation should be considered as the primary intervention in a timely fashion without further studies to abrogate continuing caloric malnutrition. In the minority of instances, when the barium esophagram demonstrates an obvious, significant anatomic abnormality such as a slipped or herniated fundoplication with nonpassage of the barium pill, we recommend expedient reoperation if dysphagia is debilitating. This may entail proceeding without a formal motility study with an understanding between the patient and surgeon that a partial fundoplication may be the anatomic outcome of reoperation and that an endoscopy will be performed in the operating room prior to surgery.

Upper endoscopy should be performed in almost all patients with persistent postoperative dysphagia, with the exception of cases where an obvious immediate diagnosis is evident on the barium esophagram. Endoscopy allows detection of additional findings not easily appreciated on a contrast study, such as eosinophilic esophagitis and/or esophageal rings. Endoscopy also better characterizes the gastroesophageal junction and fundoplication including the resistance to endoscope passage. On retroflexion, an intact Nissen fundoplication will have a characteristic long valve body adhering to the endoscope circumferentially through all phases of respiration. The gastroesophageal junction will be located below the crura, confirming the wrap is around the distal esophagus [17]. A slipped fundoplication or re-herniation of the wrap above the diaphragm, may be apparent on endoscopy and may substantiate the symptom of dysphagia within the correct clinical setting (Fig. 20.2).

Patients with severe dysphagia and a normal esophagram, or patients with an abnormal esophagram, should be referred for esophageal motility study. These results should aid in the diagnosis of any underlying esophageal motility disorder, such as ineffective esophageal motility, esophageal spasm, achalasia, or increases gastroesophageal junction pressure, which may be contributing to symptoms and can provide information that might assist with definitive treatment. The decision to operate will depend on the patient’s nutritional status and severity of dysphagia as previously noted. For those patients with persistent dysphagia, weight loss, and ineffective motility shown on manometry, we would recommend converting a Nissen to a Toupet fundoplication after maximizing nutritional status. In cases when a hypertensive lower esophageal sphincter is diagnosed in conjunction with esophageal aperistalsis, a Heller myotomy with Dor fundoplication may be performed to attempt resolution of symptoms [14–16]. Often, this may necessitate takedown of the prior fundoplication, and this procedure is usually difficult but not impossible. If motility is normal, and a slipped fundoplication without a hiatal problem is visualized, then a revision to a floppy Nissen fundoplication should be considered.

Patients with Recurrent Reflux or Heartburn Symptoms

Recurrent symptoms such as chest pain , heartburn, and regurgitation are also common in the early postoperative period and are often best managed with reassurance and attention to diet. It is worth remembering that patients with evidence of significant esophagitis or gastritis preoperatively may not have full healing of these conditions for some time after surgery. When symptoms are similar to before surgery, a trial of acid suppression is appropriate in these individuals, as they will likely resolve with therapy. When symptoms persist or recur after 3 months post-operatively, further workup is warranted. On initial consideration, it might be tempting to conclude that a partial wrap might be associated with a high rate of reflux symptoms and, consequently, frame our response to patient concerns. In reality, this is not the case. A recent meta-analysis, examining the results of 13 randomized clinical trials found no difference in persistent reflux symptoms between laparoscopic Nissen and Toupet fundoplications [18]. It may also be a surprise to many practitioners who provide both medical and surgical treatment of reflux disease, that between 2 and 40% of patient experience some degree of recurrence of their symptoms at 5 years after their initial operation [7, 11, 19, 20]. It is also worth noting that between 15% and 50% of patients are prescribed proton pump inhibitor (PPI) therapy postoperatively, mainly by their primary care provider, and that there is increased use of these medications as follow-up time increases [20, 21]. Other aggregate causes of recurrent reflux symptoms include poor initial evaluation, technically inadequate fundoplication, disrupted or slipped fundoplication, recurrent hiatal hernia with intrathoracic wrap migration, undiagnosed esophageal dysmotility, or infection. Earlier symptoms may suggest a technically inadequate initial fundoplication or a disrupted fundoplication, but both present with decreased lower esophageal sphincter pressure. With careful questioning, it is not infrequent that a patient may attribute onset of recurrent symptoms to a retching event, gastrointestinal illness, or after a particular episode of vigorous activity or coughing.

Many studies have attempted to identify predictors of poor symptomatic outcome after fundoplication, but consistent factors have not been reliably identified. One group followed patients for 11 years postoperatively and found that those with atypical symptoms, no response to acid-suppressive therapy, and those with a BMI >35 kg/m² were more likely to fail anti-reflux surgery, as evidenced by reoperation, poor patient satisfaction, or severe symptoms [22]. However, a large meta-analysis of 63 studies did not find consistent evidence that age, sex, BMI, or preoperative response to acid suppression, esophagitis, or dysmotility was associated with postoperative outcomes [23]. Based on our review of quality studies and our own experience, we have found that preoperative predictors of success after fundoplication include the presence of typical GERD symptoms, responsiveness to PPI therapy, and abnormal 24-hour pH study with a positive symptom index. We have also found that patients with atypical symptoms, or symptoms associated with cough, chest pain, or hoarseness often fail to achieve full resolution of these symptoms postoperatively.

Workup and Treatment

Recurrent symptoms of reflux alone can be poor indicators of a specific physiologic or anatomic issue, and objective studies should be performed in all cases where conventional dietary and behavior modifications have not helped. We usually start our workup with a barium esophagram and barium pill to identify anatomic abnormalities of the fundoplication or re-herniation. Barium swallow can reveal multiple abnormalities such as free reflux of contrast or loss of a normal fundoplication filling defect, suggestive of a disrupted fundoplication. A new or recurrent hiatal hernia may be present and associated with slippage of the proximal stomach above the wrap or migration of the entire wrap above the diaphragm. If these findings are seen, we recommend upper endoscopy to better delineate the anatomy and help determine if other esophageal pathology is present. If findings are normal, reassurance with or without a trial PPI therapy can be attempted. If symptoms persist, an upper endoscopy should be performed with plans for a concurrent pH study unless significant esophagitis is visualized and biopsied. With a normal esophagram, most patients will have normal follow-up studies, but up to 10% will have findings on esophagogastroduodenoscopy (EGD) that were not detected on esophagram. A disrupted fundoplication, for example, may be seen on endoscopy as a patulous gastroesophageal junction or loose wrap seen on retroflexion (Fig. 20.2) [16, 17]. When no anatomic deformities are seen on esophagram or endoscopy, a 24-hour pH monitoring study is often normal.

Definitive treatment in cases where symptoms are persistent and severe will probably warrant reoperation to reduce a hiatal hernia if one if present, or to revise the prior hiatal repair or fundoplication. When arriving at this point, a thorough workup should include esophagram, endoscopy (with biopsy as indicated by findings), and pH study. Dysmotility is occasionally reported by the radiologist performing the esophagram and is usually best confirmed with esophageal manometry. If there is significant dysmotility on manometry, even if the patient has no swallowing symptoms, we would still recommend conversion of a Nissen to a partial fundoplication to eliminate any swallowing difficulties after the reoperation. When the esophageal motility is normal, then a redo Nissen fundoplication can be performed. Careful patient counselling as to the expectations of outcomes is essential prior to any revision operation.

Reoperation for Fundoplication Failure and Resultant Symptoms

Some centers perform reoperative anti-reflux surgery through a laparotomy or thoracotomy. When undertaken by an experienced foregut team, the laparoscopic approach should be successful in over 97% of cases, especially if the initial operation was done laparoscopically. Consequently, it is generally advised that revision surgery should be performed at a high-volume foregut unit in order to optimize outcomes.

In our center, we utilize the standard five-trocar upper abdominal configuration. Adhesiolysis using the ultrasonic shears to lyse the dense gastrohepatic scarring between the left lateral section of the liver and the lesser curvature of the stomach is almost always needed before placing the liver retractor. The successful retraction of the liver above the operative field is the first critical maneuver of the operation. This gives a broad view of the anatomy and allows us to determine our initial approach for revision. The goals of the initial dissection are to completely identify and isolate the diaphragmatic hiatus and to safely identify the esophagus. Often, starting the initial approach from the patient’s left side with the intent to identify the column of the left crus is easier. Adhesions from the previously divided short gastric are easily cleared, and this allows for reduction of any recurrent hernia and the greater curvature of the stomach. Following this, a retro-gastric dissection inferior to the decussation of the right and left crura can be performed to prepare for the lesser curvature dissection. Next, we begin our lesser curvature dissection by identifying the most inferior portion of the caudate lobe of the liver. From this point, we use the harmonic scalpel to free up the dense gastrohepatic ligament scar tissue as we move superiorly toward the column of the right crus. This can be a challenging dissection, made more difficult by the usual welding of scar tissue of the prior wrap to the shoulder of the right crus. Dissection in this area – usually between the 9 and 12 o’clock position on the crura – may result in removal of some portions of Glisson’s capsule. Troublesome bleeding, as a consequence, may be treated with local application of topical agents such as Surgicel® (Ethicon, Ohio). Invariably, following the inferior margin of the caudate lobe will lead to the column of the right crus. This area is usually involved in the densest adhesions between the wrap and the hiatus, and tedious dissection from in inferior and superior may be needed to complete a 360-degree dissection around the hiatus; a Penrose drain is then placed in the abdomen, and the distal esophagus is encircled with it. Gentle tension on the Penrose drain facilitates reduction of the stomach and distal esophagus into the abdomen so as to facilitate a circumferential mediastinal dissection . In reoperative surgery, a pleural rent (particularly on the left) is not uncommon and can lead to a capnothorax. Good communication between the surgical and anesthesia teams can identify any pulmonary or hemodynamic consequences of this. Usually, pausing the operation and releasing pneumoinsufflation, or passing a red rubber catheter into the rent will help equalize the pressure in the chest and abdomen and allow for the case to progress. Unusually, a thoracostomy tube may have to be placed in instances where pulmonary or hemodynamic instability is profound and not responsive to less-invasive means.

Once the fundoplication and distal esophagus are mobilized from the chest, the fundoplication is taken down with sharp dissection along the track of the prior anterior sutures. Adhesions formed between the fundoplication and upper stomach are divided to recreate normal anatomy. Identification of the anterior and posterior vagus nerves during this dissection is important to minimize the chance of injury. At times, an old hernia sac or gastroesophageal fat pad remnant is seen and resected. Next, with the esophagus and stomach in their normal position off tension, intra-abdominal esophageal length is assessed. If 3 centimeters of intra-abdominal esophagus is not present, a Collis gastroplasty should be performed. Any hiatal defect is then closed over a bougie with interrupted permanent sutures (we prefer 0-Ticron with felt pledgets) with or without mesh reinforcement. Recreation of a fundoplication will be determined by the patient’s underlying esophageal motility and symptoms .

While the success rates of first operations are between 90 and 95%, each successive operation is associated with deteriorating results [16]. Generally, second and third operations are successful between 80–90% and 50–66% of the time, respectively. Considering that fourth operations are rarely successful, some experts would recommend creation of a subtotal gastrectomy with Roux-en-Y gastrojejunostomy or esophageal resection .