Etiology and management of post-fundoplication dysphagia

Laparoscopic fundoplication is becoming more popular in patients with gastroesophageal reflux disease. Transient dysphagia is very common following fundoplication. Fortunately, dysphagia usually resolves spontaneously within 4 to 6 weeks. However, approximately two to 14% of patients develop significant post-fundoplication dysphagia. There are many different factors contributing to post-fundoplication dysphagia. The most common causes are improper surgical technique and surgery selection for each patient. Barium esophagram and upper endoscopy should be obtained to determine the integrity of the fundoplication. A slipped fundoplication is present when the wrap is around the stomach rather than the esophagus, indicating either that it was incorrectly placed at initial surgery or pulled out of its attachments. Endoscopic dilation should be attempted in all patients with severe or persistent post-fundoplication dysphagia. It will be effective in about half of the patients. Patients with evidence of a slipped fundoplication, previous multiple antireflux surgeries, or refractory dysphagia despite dilations beyond 4 months are predictors of poor outcome for endoscopic dilation, and they should be considered for re-operation.