Evaluation and management of postfundoplication dysphagia

Objectives: Persistent dysphagia occurs in 3-24% of patients after fundoplication. There are virtually no data on the success or safety of endoscopic dilation to relieve postfundoplication dysphagia. The aim of this study was to review our experience with endoscopic management of patients with dysphagia after fundoplication. Materials and Methods: Thirty-five patients (mean age 49 yr; 12 males, 23 females) with dysphagia after fundoplication were referred for endoscopic dilation. Twenty-nine patients had undergone one fundoplication (group A), and six patients had undergone two or more operations (group B). The integrity of the fundoplication was evaluated by barium esophagram and upper endoscopy. Median follow-up after the initial postoperative dilation was 13 months. Results: The 29 patients in group A were dilated to a mean (±SD) of 52 ± 4F during a mean (±SD) 1.9 ± 1.1 dilation sessions per patient. No complications, such as disruption of the fundoplication, resulted from endoscopic dilation, and no one developed new reflux symptoms. Dysphagia resolved in 15 (52%) patients after dilation. The most important prognostic feature was endoscopic or radiological evidence of a slipped fundoplication. Dilation was successful in relieving dysphagia in only three of 11 (27%) patients with a slipped fundoplication, compared with 12 of 18 (67%) patients with an intact fundoplication (p = 0.05). Dysphagia resolved in only one of the six patients in group B. Conclusions: Endoscopic dilation is safe and often effective in patients with postfundoplication dysphagia. However, patients with a slipped fundoplication or who have undergone multiple fundoplications respond poorly to endoscopic dilation.