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ORIGINAL ARTICLE
            Dysphagia after Bougie-guided Crural Repair in Laparoscopic

            Nissen Fundoplication


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            Mohab G Elbarbary , Islam Hossam El-Din El-Abbassy , Ahmed Samy Omar , Medhat Helmy Khalil 4
             AbstrAct
             Purpose: Nissen fundoplication is still assumed as the perfect lifelong management for gastroesophageal reflux disease (GERD). Despite the
             marked progress in performing the operation laparoscopically, dysphagia remains the most common postoperative morbidity. The use of an
             intraesophageal bougie during fundoplication to decrease the risk of postoperative persistent dysphagia (PD) by a forming proper tension-free
             wrap has been reported before in the literature. However, the aim of our study was to highlight the role of using a bougie in allowing a more
             guided way to repair the crura and avoiding blinded posterior repair, and the effect of that in reducing the incidence of postoperative PD in
             laparoscopic Nissen fundoplication.
             Materials and methods: A prospective study including 40 patients undergoing laparoscopic Nissen fundoplication for repairing hiatal hernia
             with refractory GERD. The crural repair was guided by 50 Fr bougie. Postoperative collection of GERD–health-related quality of life (GERD–HRQL)
             questionnaire was done at 1 and 6 months for all the patients. The postoperative dysphagia was assessed regarding both severity and frequency.
             Results: The GERD symptoms significantly improved in all patients, with marked postoperative satisfaction. No patients required dilation for
             postoperative dysphagia. Ten patients (25%) had mild dysphagia that resolved with conservative management, but no recurrence of GERD
             symptoms was observed.
             Conclusion: Laparoscopic Nissen fundoplication is more efficient on using a bougie, allowing proper identification of the direction of esophageal
             descent through the hiatus, resulting in proper crural repair and the formation of an ideal wrap with a low-risk of prolonged dysphagia.
             Keywords: Bougie, Dysphagia, Gastroesophageal reflux, Hiatal hernia, Nissen fundoplication.
             World Journal of Laparoscopic Surgery (2022): 10.5005/jp-journals-10033-1520


            IntroductIon                                       1,3,4 Department of General Surgery, Ain Shams University, Cairo, Egypt
            Postoperative dysphagia is considered one of the most annoying   2 Department of General Surgery, Faculty of Medicine, Ain Shams
            complications for patients having laparoscopic fundoplication.   University, Cairo, Egypt; Raigmore Hospital, NHS Highland, United
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            About 40–70% of patients would suffer from transient dysphagia.    Kingdom; Institute of Medical Sciences, University of Aberdeen,
            Despite the unclearness of the exact cause, the ineffective   Aberdeen, United Kingdom
            esophageal motility (IEM) and postoperative edema at the   Corresponding Author: Islam Hossam El-Din El-Abbassy, Department
            gastroesophageal junction (GEJ) may give an idea about that. 2  of General Surgery, Faculty of Medicine, Ain Shams University, Cairo,
               Dysphagia commonly resolves spontaneously within 2–3   Egypt; Raigmore Hospital, NHS Highland, United Kingdom; Institute of
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            months postoperatively;  however, PD may occur in 3–24% of   Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom,
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            patients after Nissen fundoplication.  Laparoscopic fundoplication   Phone: +44 7871798087, e-mail: islamelabbassy@hotmail.com
            was believed to have a higher incidence of PD than the open   How to cite this article: Elbarbary MG, El-Abbassy IH El-Din, Omar AS,
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            approach.  Construction of a tight wrap, slippage or displacement of   et al. Dysphagia after Bougie-guided Crural repair in Laparoscopic
            fundoplication, a peptic ulcer stricture, as well as dividing the short   Nissen Fundoplication. World J Lap Surg 2022;15(2):140–144.
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            gastric vessels during fundus mobilization are all possible causes.    Source of support: Nil
               Unfortunately, undiagnosed IEM and unrecognized achalasia   Conflict of interest: None
            preoperatively  may  have  a  role  in  raising  the  incidence  of
            postoperative PD. 7
               The use of an intraesophageal bougie during fundoplication to   We included patients having hiatal hernia with refractory GERD
            decrease the risk of postoperative PD by forming proper tension-  who were not compliant with medical therapy. Patients who suffered
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            free wrap has been reported before in the literature.  However,   from achalasia or any esophageal motility disorders were excluded
            the aim of our study was to highlight the role of using a bougie in   along with patients having previous esophageal or gastric surgery,
            allowing a more guided way to repair the crura and avoiding blinded   or those over 60 years of age. All patients had laparoscopic Nissen
            posterior repair and the effect of that in reducing the incidence of   fundoplication by a team of two skilled surgeons using the same
            postoperative PD in laparoscopic Nissen fundoplication.   technique.
                                                                  We conducted this study in compliance with the principles of
                                                               the Declaration of Helsinki. The study’s protocol was reviewed and
            MAterIAls And Methods                              approved by the institutional ethical committee. Written informed
            This was a prospective observational study conducted during the   consent was obtained from all patients included in the study.
            period from July 2017 to December 2019 at Ain Shams University   A standardized GERD–HRQL questionnaire 9,10  was used for all
            Hospitals, Cairo, Egypt.                           patients preoperatively and at 1 and 6 months postoperatively.

            © The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
            org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
            the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
            Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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