Nissen Fundoplication and Dysphagia
“Clinical Significance of Esophageal Outflow resistance Imposed by a Nissen Fundoplication”, is a new study published by Demeester el al in the journal of the American College of Surgeons, JACS. Using esophageal manometry, the authors measured intrabolus pressure in normal subjects and in acid reflux patients undergoing Nissen fundoplication before and after surgery. They showed that Nissen fundoplication significantly increases intrabolus pressure. The authors concluded that Nissen fundoplication should be constructed in such a way as to avoid an intrabolus pressure higher than 20 mmHg. As long as patients have a distal esophageal contraction amplitude higher than 20 mmHg, they are at minimal risk for postoperative dysphagia.
Indeed, at Houston heartburn and reflux Center, dysphagia after Nissen fundoplication is rare. Advanced surgical technique, comprehensive pre-operative evaluation, and extensive experience in the field of acid reflux management allow us to maintain a very low dysphagia rate. Esophageal manometry is an important test performed prior to Nissen fundoplication. Manometry evaluates peristaltic vigor and lower esophageal sphincter relaxation pressure. At Houston heartburn and Reflux Center, our cutoff point for distal esophageal contraction amplitude is 25 mmHg. Patients with values lower than 25 mmHg are more likely to undergo a partial fundoplication like Toupet fundoplication to avoid postoperative dysphagia. We agree with the authors that a loose and floppy Nissen fundoplication must be constructed to decrease outflow resistance. Patients with normal manometry but small gastric fundus end up with a partial fundoplication to avoid a tight Nissen fundoplication and associated dysphagia.
To summarize, in expert hands, properly selected acid reflux patients undergoing Nissen fundoplication are at very low risk for postoperative dysphagia