Page 47 - World Journal of Laparoscopic Surgery

Dysphagia after Bougie-guided Crural Repair
(1–2 cm) and dividing the short gastric vessels was effective in fundoplication is more efficient by using a bougie, allowing proper
preventing PD among our patients. identification of the direction of esophageal descent through the
The use of intraesophageal bougie guide during the wrap hiatus resulting in proper crural repair and the formation of an ideal
formation was first adopted by a study in 1986 showing a lower risk wrap with a low-risk of prolonged dysphagia.
of developing postoperative dysphagia when a larger bougie was
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used. The Society of American Gastrointestinal and Endoscopic Clinical Significance
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Surgeons (SAGES) recommended the bougie use supported In our technique, the use of a 50 Fr bougie was considered the gold
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by another study. However, on the other hand, several studies standard step in deciding how to repair the crura (either anteriorly,
assumed that the rates of postoperative dysphagia were not affected posteriorly or both) and forming the ideal wrap in laparoscopic
and the possible benefit decreased by the risk of esophageal Nissen fundoplication, minimizing the risk of too much or too
perforation. 22,25,26 In our study, no esophageal perforations were loose crural repair with low-risk of prolonged dysphagia. To our
reported while introducing the bougie by experienced anesthetists. knowledge, our study is the first to highlight the importance of
The idea of using a bougie in our study was not only to decrease repairing the crura under vision guided by the bougie, whereas
the risk of postoperative dysphagia by forming proper tension-free there is no documentation in the literature about the effect of crural
wrap but also to allow a more guided way to repair the crura and repair, which may be a cause of the reported incidence of PD after
avoid blinded posterior repair. Due to the presence of posterior laparoscopic Nissen fundoplication.
esophageal sagging (which commonly occurs with those patients
due to repeated reflux and esophageal inflammation), a blinded orcId
posterior repair without checking the direction of the esophageal
descent through the hiatus may result in incomplete closure of the Islam ElAbbassy https://orcid.org/0000-0001-9359-9726
hiatus or tightening of the hiatal defect resulting in fundoplication
failure (by wrap migration into the chest due to wide hiatus or references
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wrap, minimizing the risk of too much or too loose crural repair. To 2. Low DE. Management of the problem patient after antireflux surgery.
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Nissen fundoplication, PD was reported to range 3–24%. 16,27 5. Perdikis G, Hinder RA, Lund RJ, et al. Laparoscopic Nissen fundopli-
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70% of our patients, all of which resolved conservatively within 4 6. Watson DI, Jamieson GG, Mitchell PC, et al. Stenosis of the eso-
weeks. In the literature, the incidence of postoperative gas-bloating phageal hiatus following laparoscopic fundoplication. Arch Surg
15
syndrome was reported to reach 85%. This could be related to 1995;130(9):1014–1016. DOI: 10.1001/archsurg.1995.01430090100029.
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the extensive division of the short gastric vessels or due to the 7. Watson DI, Pike GK, Baigrie RJ, et al. Prospective double-blind
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