“Laparoscopic Nissen fundoplication improves disease specific quality of life in patients with GERD and functional esophageal outflow obstruction” is a recently published study in Surgical Endoscopy. The authors demonstrate that functional esophageal outflow obstruction noted on manometry in acid reflux patients is not a contraindication for Nissen fundoplication. 211 acid reflux patients underwent Nissen fundoplication between 2009 and 2017. 7% of 211 patients had functional esophageal outflow obstruction on manometry. There was no difference in baseline dysphagia scores and at one year follow up post Nissen fundoplication in both groups. Both groups showed similar improvement in acid reflux symptom control and disease specific quality of life.
Functional esophageal outflow obstruction is diagnosed using esophageal manometry. It is characterized by an elevated integrated relaxation pressure, IRP, greater than 15 mmHg in the setting of preserved esophageal peristalsis. Functional esophageal outflow obstruction is not associated with a structural or anatomic abnormality like a stricture, tumor or eosinophilic esophagitis. In the setting of GERD, we have noted, at Houston heartburn and Reflux Center, increased adhesions around the distal esophagus and lower esophageal sphincter in patients with esophageal outflow obstruction. Concomitantly, most GERD patients with esophageal outflow obstruction and increased adhesions around distal esophagus have small hiatal hernias. We believe that these peri-esophageal adhesions are secondary to severe acid reflux. Furthermore, excessive scar tissue formation around the distal esophagus prevents hiatal hernias from growing over time and contributes to esophageal outflow obstruction. It is possible that inflammation and adhesion formation prevent lower esophageal sphincter from properly relaxing. Hiatal hernia dissection and distal esophageal mobilization followed by floppy Nissen fundoplication reliably stops acid reflux. Such approach releases the adhesions contributing to outflow obstruction and stops acid reflux, the underlying cause of adhesion formation in this case. Consequently, we agree with the authors that the best treatment for functional esophageal outflow obstruction in GERD patients is laparoscopic Nissen fundoplication and hiatal hernia repair.