Journal Information
Vol. 86. Issue 2.
Pages 211-212 (April - June 2021)
Vol. 86. Issue 2.
Pages 211-212 (April - June 2021)
Letter to the Editor
DOI: 10.1016/j.rgmxen.2020.11.002
Open Access
Post-fundoplication dysphagia: Laparoscopic intervention or endoscopic dilation?
Disfagia posfunduplicatura: ¿intervención laparoscópica o dilatación endoscópica?
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F. Tustumia,b,c,
Corresponding author
franciscotustumi@gmail.com

Corresponding author at: Domicilio: Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, SP, Code: 05403-000. Tel.: +55 (11) 2661-7560.
, L. Nogueira Datrinoc, M.C. Andrade Serafimc, M.F. Orlandinic, A.L. Gioia Morrellb,c,d
a Universidade de São Paulo, São Paulo, Brazil
b Hospital Israelita Albert Einstein, São Paulo, Brazil
c Centro Universitário Lusíada, São Paulo, Brazil
d Instituto Morrell, São Paulo, Brazil
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We read the original article by Godoy-Salgado et al.1 with great interest, in which they described their experience in managing post-fundoplication dysphagia associated with esophagogastric junction obstruction. The authors reported that esophageal dilations were carried out on all the patients, but with no improvement. Whether to perform pneumatic dilation or a laparoscopic intervention is always a difficult decision. In addition to the considerable possibility of unsatisfactory dysphagia resolution, perforation is the main risk involved in carrying out pneumatic dilation.

Various studies have failed to find predictive variables for pneumatic dilation success, including endoscopic, radiologic, or manometric factors.2 However, a greater chance for success largely depends on the correct diagnosis of the etiology of post-fundoplication dysphagia. Therefore, having a high-quality medical history and choosing the correct tests are essential.

First of all, the surgeon must follow the “do no harm” principle. Before performing the fundoplication, the past medical history must include the presence or absence of dysphagia, and even nondysphagic patients should undergo preoperative esophageal manometry, to detect esophageal dysmotility disorders. Once fundoplication has been decided upon, only expert foregut surgeons should perform the surgery, to prevent technical errors. A laparoscopic fundoplication video should be recorded for future review, in the case of dysphagia.

When post-fundoplication dysphagia has been established, its time of onset should be determined and the dysphagia classified as transient, early persistent, or late.

Transient dysphagia occurs in 40-70% of patients after fundoplication.3 The cause is unknown, but the condition is usually tolerable and resolves within 3 months, so no further investigation is needed.3 However, if disabling symptoms persist, it is considered early persistent dysphagia, and is usually related to technical errors. It can be related to a tight crurorraphy or tight wrap, or due to a misplaced/twisted wrap. The video of the procedure should be analyzed, and if an isolated mistake is observed, it should be laparoscopically corrected. Esophagogram and endoscopy may help identify the error. Only if the exams show fair signs of obstruction, should pneumatic dilation be used.

If the dysphagia begins a long time after surgery, the differential diagnoses are wrap migration, adhesions,2 late onset achalasia, or even cancer (mainly in Barrett’s esophagus). If esophagogram and endoscopy detect wrap migration, the laparoscopic approach will probably be much more effective than pneumatic dilation, which does not resolve the structural problems.4 If no relevant migration is observed and no dysmotility is detected in the manometric evaluation, local adhesions could be the cause of the dysphagia. In that context, pneumatic dilation could be sufficient.

Pneumatic dilation is a therapeutic option, under certain conditions. However, when laparoscopic intervention is indicated, it should not be delayed, given the risk of esophageal perforation during progressive pneumatic dilations, or the risk of developing pseudoachalasia, due to long-term persistent gastroesophageal obstruction.

The present letter to the editor complies with all ethics standards.

Authorship

All authors approved the final version of the article and have materially participated in the research and/or article preparation.

Conflict of interest

The authors declare that there is no conflict of interest.

References
[1]
Godoy-Salgado DC, Toro-Monjaraz EM, Padilla-Cortés T, et al.Obstrucción del tracto de salida de la unión esofagogástricaen el diagnóstico diferencial de disfagia posfunduplica-tura en niños. 2020; S0375-0906:30082-3, https://doi.org/10.1016/j.rgmx.2020.06.003
[2]
S. Samo, R. Mulki, M.L. Godiers, et al.
Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia.
[3]
K. Sato, Z.T. Awad, C.J. Filipi, et al.
Causes of long-term dysphagia after laparoscopic Nissen fundoplication.
JSLS, 6 (2002), pp. 35-40
[4]
S. Sobrino-Cossío, J.C. Soto-Pérez, E. Coss-Adame, et al.
Post-fundoplication symptoms and complications: Diagnostic approach and treatment. Síntomas y complicaciones posfunduplicatura: abordaje diagnóstico y tratamiento.
Rev Gastroenterol Mex, 82 (2017), pp. 234-247

Please cite this article as: Tustumi F, Nogueira Datrino L, Andrade Serafim MC, Orlandini MF, Gioia Morrell AL, Disfagia posfunduplicatura: ¿intervención laparoscópica o dilatación endoscópica? Revista de Gastroenterología de México. 2021;86:211–212.

Copyright © 2021. Asociación Mexicana de Gastroenterología
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