Persistent Postoperative Dysphagia

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In contrast to the patient with recurrent GERD symptoms, the patient with persistent postoperative dysphagia represents a different problem. The management of the patient with early postoperative dysphagia was discussed above. In the patient with dysphagia persistent for >3

months, we first confirm an anatomic abnormality exists by performing a video barium swallow with a 12.5-mm barium tablet. If the pill passes the gastroesophageal junction readily, there is little that one can do to fix the "problem." Under these circumstances, the dys-phagia is usually functional, or may indicate ineffective esophageal peristalsis. Thus, a normal barium swallow should be followed by an esophageal motility study in patients with significant dysphagia. If the barium tablet hangs up at the gastroesophageal junction, the problem is most likely related to the fundopli-cation itself, or otherwise undetected achalasia or other lower esophageal sphincter motor pathology. For this reason, a motility study is helpful, but only in preparation for a redo oper

PERSISTENT SYMPTOMS AFTER ANTI-REFLUX SURGERY AND THEIR MANAGEMENT

ation or to detect previously unrecognized preoperative primary esophageal dysmotility unrelated to the anti-reflux surgery. The decision to reoperate or not must be individualized based on the patient's nutritional status and the severity of the dysphagia. Early elective reoperation should be performed in patients who are confined to liquids after 3 months of watchful waiting, and patients who are losing weight because of persistent dysphagia. However, if solid food dysphagia is mild, dietary restrictions are few, and weight loss is not present, we prefer a conservative course of management for at least 1 year postoperatively. During that year,

>50% of patients will resolve their postoperative dysphagia without any intervention. However, if a barium tablet still hangs up at the distal esophagus 1 year postoperatively, and the patient is still bothered by dietary restrictions, a second operation is usually offered. A third scenario is one in which the barium tablet may or may not hang up, but the barium swallow demonstrates an obvious anatomic difficulty such as a slipped or herniated fundoplication. These patients will usually do best with reoperation and this is what we most often recommend. Although esophageal dilatation may be beneficial for early postoperative dysphagia, it is rarely helpful after

Slipped Fundoplication
Figure 7.3. A retroflex gastroscope identifies most abnormalities of the fundoplication. A, Retroflexed view of a well-formed Nissen fundoplication. B, A herniated fundoplication. C, A twisted valve in a "two-compartment stomach." D, Partially disrupted fundoplication.

MANAGING FAILED ANTI-REFLUX THERAPY

3 months postoperatively, especially if it has been used previously and failed.

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