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Dysphagia after Bougie-guided Crural Repair
            resolved within 8 weeks postoperatively, while late dysphagia
            was defined by having PD that time and requires endoscopic
            intervention and/or surgery for resolution. 13,14
               Any investigations required for postoperative dysphagia were
            recorded.

            results
            All our 40 patients had laparoscopic Nissen fundoplication using
            our technique for chronic GERD with sliding hiatal hernia during
            the given period of time.
               The study included 10 males (25%) and 30 females (75%). The
            median age was 44 years. Sliding hiatal hernias were detected
            in all patients as proven by preoperative upper GI endoscopy
            with sizes ranging from 1 to 5 cm. Four patients (10%) showed
            Barrett’s metaplasia with no dysplasia in the histology taken upon
            esophagogastroduodenoscopy (EGD) before the procedure. All
            patients showed various degrees of esophagitis.    Fig. 3: Degree of postoperative dysphagia in our patients guided by
               The preoperative symptoms were heartburn (n = 34, 85%) and   Saeed et al.  classification at 1 and 6 months postoperatively
                                                                       12
            regurgitations (n = 24, 60%). Aspiration was manifested as chronic
            cough or asthma with recurrent pneumonia.             No  further  investigations were  required  for  the  rest  of
               All patients were diagnosed to have refractory GERD with   the patients included in the study influenced by the marked
            prolonged usage of PPIs. Demography and preoperative symptoms   improvement of their symptoms.
            are shown in (Table 2).
               The median operation time was recorded to be 85 minutes in the
            range 30–180 minutes. All operations were done laparoscopically  dIscussIon
            with no conversion to open. We had no intraoperative complications.   Despite the marked effect of PPIs in treating GERD, the surgical
            The introduction of the 50 Fr bougie was done by a senior   approach is considered the most effective long-term management
            experienced anesthetist with no intraoperative complications   of the disease. Laparoscopic Nissen fundoplication is still the most
            associated with its use.                           effective anti-reflux surgery, with marked patient satisfaction and
               Postoperatively, GERD symptoms (heartburn, regurgitation,   minimal postoperative complications. 15
            and aspiration) significantly improved in all patients and the GERD–  However, the prevalence of complications such as postoperative
            HRQL scores showed marked postoperative satisfaction. Symptoms   dysphagia and gas-bloat syndrome may occasionally require
            resolved without using PPIs in 38 patients (95%), whereas occasional   further surgical intervention and decrease the postoperative
            PPI intake was reported in 2 patients (5%)         patients’ satisfaction.  Postoperative dysphagia could be caused
                                                                               16
               Early dysphagia was reported postoperatively in ten patients   by slipping of the wrap  or local edema and hematoma resulting
                                                                                 16
            (25%). Four patients (10%) had rare difficulties in swallowing solids,   from excessive manipulation during the procedure.
                                                                                                      13
            whereas six patients (15%) were reported to have occasional   In our study, 25% of our patients were managed conservatively
            difficulties in swallowing solids.                 for early dysphagia and only two patients required upper GI
               All patients were reachable for follow-up (either by phone   endoscopy due to repeated vomiting, which showed mild narrowing
            or attending the clinic), and they were willing to take part in the   not requiring dilatation. The passage of the scope itself may have
            questionnaire.                                     contributed to achieving some sort of calibration. It has been
                                              12
               Guided by the classification of Saeed et al.,  both severity and   reported that early postoperative mild dysphagia is common shortly
            frequency of dysphagia following our procedure were evaluated   after the operation and improves spontaneously when edema or
            at 1 and 6 months as shown in Figure 3. Postoperative gas-bloat   hematoma subsides, whereas PD that lasts more than 8 weeks
            syndrome was reported in 28 patients (70%); however, these   occurs in 20% of cases and is considered a challenge in further
            symptoms improved in all patients within 4 weeks postoperatively.   diagnosis or treatment.  Postoperative dysphagia could also be
                                                                                 17
            Only two patients (5%) with repeated vomiting needed postop-  due to possible technical errors by the surgeon due to closing the
            erative upper GI endoscopy, which showed mild narrowing not   hiatus too much or making a too-tight wrap.  Proper preoperative
                                                                                                18
            requiring dilatation. Those patients were managed conservatively.  diagnosis for the cause of GERD is very important as the presence of
                                                               preoperative dysphagia or esophageal motility disorder, increases
            Table 2: Demographic data and the preoperative findings  the development of PD postoperatively. 19
                                   Number of patients   Percentage    There have been some suggestions in the literature to decrease
                                                                                                                1
             Data                    (total, N = 40)   (%)     the chance of developing postoperative dysphagia. DeMeester
                                                               reported that reducing the wrap length from 4 to 1 cm, along with
             Males                       10            25
                                                               division of the short gastric vessels and increasing the size of the
             Females                     30            75      bougie from 36 to 60 Fr was enough to reduce the incidence of
             Preoperative heartburn      34            85      postoperative dysphagia from 83 to 40%. However, the effect of
                                                               division of the short gastric vessels to perform a better tension-free
             Preoperative regurgitation  24            60
                                                               wrap, on decreasing the incidence of PD is still controversial. 20,21
             Barrett's metaplasia          4           10      In our study, using a 50 Fr bougie along with doing a short wrap

            142   World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022)
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