• What Happens When You Have Dysphagia After Anti-Reflux Surgery?

What Happens When You Have Dysphagia After Anti-Reflux Surgery?

In patients who develop dysphagia within a few weeks after fundoplication surgery for gastroesophageal reflux disease (GERD), most symptoms resolve with time and require no intervention. However, patients with clinically significant dysphagia months after this surgery benefit from endoscopic dilation, researchers report in the September issue of Clinical Gastroenterology and Hepatology. The authors studied the prevalence of dysphagia after fundoplication and factors associated with outcomes.

Change in late post-fundoplication dysphagia by management strategy. (A) Any late postfundoplication dysphagia. (B) Clinically significant late postfundoplication dysphagia. Endoscopic dilation and surgical revision both resulted in significant improvement in dysphagia scores, whereas medical management did not.

Anti-reflux surgery is an important management option for GERD, but 6% to 25% of patients develop dysphagia after this treatment. This dysphagia affects quality of life, leading to dissatisfaction with surgery.

There have been recent advances in management of esophageal motility disorders. Methods for analysis of post-fundoplication dysphagia include esophagogastroduodenoscopy, barium radiography, esophageal manometry, and ambulatory pH or pH impedance testing. Therapeutic options include medical management, endoscopic dilatation, and/or surgical revision. However, there have been few comprehensive studies of outcomes of treatments for post-fundoplication dysphagia, factors associated with improvement, or factors that affect clinical decision making.

Stephen Hasak et al aimed to determine the prevalence and course of post-fundoplication dysphagia in patients with GERD who underwent anti-reflux surgery and to identify factors associated with outcomes. Esophageal symptoms were assessed using a validated questionnaire.

In their retrospective analysis of 157 adults with GERD, 64.3% reported post-operative dysphagia; about half reported clinically significant dysphagia, defined as a score of 2 or more on the 5-point Likert scale. In total, 54.8% had early dysphagia (within 6 weeks after surgery).

Of the 32 patients (20.4%) with clinically significant early dysphagia, 13 (41.9%) improved with conservative management and 3 (3.5%) with endoscopic intervention.

Late dysphagia (median 9 months after surgery) occurred in 18.5% of patients. Of the 29 patients with clinically significant late dysphagia, 9 patients (31.0%) were managed medically, 13 (44.8%) were treated with endoscopic dilation, and 10 (34.5%) required repeat surgery.

Most patients who underwent endoscopic or surgical intervention had improved symptoms; medical management did not improve symptoms (see figure). Lack of pre-surgery contraction reserve was the only factor associated with the odds of developing late dysphagia (odds ratio, 3.73).

The mean satisfaction score was 7.9±0.2 on a 10-pt visual analog scale. Although satisfaction scores were lower among patients with any dysphagia compared with no dysphagia, the scores were lowest in patients with clinically significant late post-fundoplication dysphagia.

Based on these results, clinicians can tell patients that, although more than half of patients undergoing antireflux surgery develop dysphagia, most patients with early dysphagia improve with conservative management. Endoscopic therapy is an effective option for patients with late dysphagia. Evaluating pre-surgery contraction reserve on manometry can help identify patients at higher risk for late dysphagia.

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