Is a floppy valve a good guarantee against postoperative dysphagia

Whilst antireflux surgery, and in particular total fundoplication, is an effective treatment for gastroesophageal reflux disease, it is followed by troublesome dysphagia in some patients. This adverse outcome can spoil an otherwise good surgical result, and it will even require surgical revision in a small number of patients [1]. postfundoplication dysphagia can follow a range of problems, and in some patients the problem is due to more than one problem.

Many surgeons and gastroenterologists believe, perhaps at times simplistically, that this problem is due to the construction of an overly tight total fundoplication, and that the routine construction of a very loose total wrap (by fully mobilising the gastric fundus) or a partial fundoplication will prevent postoperative dysphagia. Unfortunately other problems can also contribute to dysphagia. For example, a narrow diaphragmatic hiatus due to the formation of dense perihiatal scar tissue [2], or even over tightening of the hiatus during hiatal repair, can be troublesome, and in our hospital narrowing of the hiatus due to perihiatal fibrosis has been the commonest problem requiring surgical revision.

Another potential cause of dysphagia can be the construction of a circumferential wrap in patients with absent esophageal body peristalsis (adynamic esophagus). Our preference in this situation is to perform a partial fundoplication procedure. A more serious problem is the formation of a total fundoplication in a patient with achalasia, who was misdiagnosed with reflux preoperatively. The use of esophageal manometry should prevent this problem. A further cause of early postoperative dysphagia can be "esophageal ileus". We have recently shown that esophageal motility is absent in most patients in the early period following laparoscopic fundoplication, but that normal motility returns at later follow-up [3]. This may explain some of the early dysphagia most patients experience following fundoplication.