Page 44 - World Journal of Laparoscopic Surgery

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.

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