Introduction

Gastroesophageal reflux disease (GERD) is a common condition in the Western World affecting 15–30% of the population.1 The constantly rising incidence is partially due to increasing obesity rates in prosperous countries. Laparoscopic Nissen fundoplication represents the gold standard in the surgical treatment of GERD. Postoperative reflux control is excellent and complication rates are low.2,3 Common side effects after Nissen fundoplication such as early postoperative dysphagia due to mucosal edema and increased bloating are usually temporary.2,4 Persistent dysphagia and gas-bloat syndrome are less frequent but in affected individuals can result in poor quality of life.5 While a recurrent hiatal hernia or a slipped/disrupted fundoplication as underlying etiology for protracted symptoms has to be addressed by a redo-Nissen, no treatment algorithm is defined for cases without such findings. Therapy options include endoscopic dilation, Botox injection, and conversion from Nissen to Toupet fundoplication. Numerous publications have reported satisfactory outcomes of primary Toupet fundoplication but the results of conversion to Toupet fundoplication for persistent dysphagia and bloating following Nissen are less clear.

The aims of this study were to determine the impact of conversion on dysphagia and bloating and to assess its effects on reflux control and quality of life.

Methods

A retrospective chart review was performed to identify all patients who had undergone conversion from Nissen to Toupet fundoplication for protracted dysphagia or gas-bloat syndrome between 2001 and 2014 at the University of Southern California. Patients undergoing conversion for a recurrent hiatal hernia or a slipped, disrupted, or twisted Nissen fundoplication were excluded from the study. A search for current contact information was performed in an attempt to locate all patients. A structured telephone interview was conducted to assess symptomatic outcome and patient satisfaction. Patients were also asked to complete the Gastroesophageal Reflux Disease-Health Related Quality Of Life (GERD-HRQL) questionnaire.6–8

This study was approved by the Institutional Review Board of the University of Southern California.

Perioperative Management and Surgical Technique

Preoperative evaluation prior to conversion included upper endoscopy, 24 or 48 h pH-metry, a video esophagram (VEG), and selectively esophageal manometry.

Conversion was performed laparoscopically in most cases. The anterior portion of the Nissen fundoplication was identified and mobilized off of the esophagus. An endoscopic linear stapler was then used to separate the Nissen. The new endings were affixed to the lateral esophagus with 2–0 silk sutures at each side to create a partial 270° dorsal wrap. At the end of the procedure, an upper endoscopy was performed to inspect the new fundoplication.

Postoperatively, all patients had a VEG prior to hospital discharge and were instructed to stay on a soft diet for 7 days.

Assessment of Symptomatic Outcomes, GERD-HRQL, and Patient Satisfaction

The telephone interview was conducted by one of two investigators and followed a standardized protocol. The presence and severity of foregut symptoms after the redo fundoplication was evaluated using a foregut questionnaire.

Patients also completed the GERD-HRQL questionnaire. The GERD-HRQL (Table 1) is an instrument that was developed to objectively quantify symptom severity in patients suffering from gastrointestinal reflux disease. It consists of 11 items that address symptoms of heartburn, dysphagia, odynophagia, and gas bloat, as well as the effect of medical therapy and a global assessment of the patient’s current health. Each of the first 10 items is scored from 0 to 5, with a lower score indicating a better QOL. The maximum total score reachable is 50. The 11th item is used to assess the patient satisfaction regarding the current health condition.8

Table 1 GERD-HRQL: Each question is scored 0–5 with higher scores indicating stronger GERD symptoms
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Patients were also asked to rate their postoperative outcome and symptom relief as satisfied, neutral, or dissatisfied.

Statistical Analysis

Statistical analysis was performed using SPSS® statistics 20.0 (IBM, Armonk, NY). Data were described using median (interquartile range) or mean (range). Statistical analysis appropriate for non-parametric data was used. Statistical significance was defined as a p value <0.05.

Results

There were 49 patients who underwent conversion from Nissen to Toupet during the study period at our institution. Of these, a total of 25 patients (16 females, 9 males) met inclusion criteria and were included in the study. Twenty-two patients could be located and agreed to complete the telephone interview. Demographic and clinical data are shown in Table 2.

Table 2 Demographic and clinical data
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The initial Nissen fundoplication was performed at our institution in 12 patients (48%) and at an outside facility in 13 patients (52%). The indication for the Nissen fundoplication was gastroesophageal reflux disease (GERD) in 22 patients (88%) while it was a paraesophageal hernia (PEH) in 3 patients (12%). The procedure could be accomplished laparoscopically in 96% (n = 24) of cases.

Conversion to Toupet Fundoplication

Indications for conversion were persistent dysphagia in 19 (76%) and bloating syndrome in 6 (24%) patients. Onset of the postoperative dysphagia was immediate in 9 patients (36%), within weeks in another 9 patients (36%), within months in 4 patients (16%), or after years in 3 patients (12%) after the Nissen fundoplication. Ineffective treatment attempts prior to conversion included endoscopic dilations in 14 patients, Botox injection in 2 patients and redo-Nissen in 1 patient. Preoperative evaluation by manometry and/or video esophagram showed an intact Nissen fundoplication with no evidence of recurrent hiatal hernia in all patients. Non-specific esophageal motility abnormalities were identified in 13 cases (52%) while 1 patient (4%) was found to suffer from achalasia type I.

The median time between the initial Nissen fundoplication and conversion was 3.7 years (IQR, 1.4–10.5). Median age at surgery was 60 years (IQR, 48–73). Conversion was accomplished laparoscopically in 23 patients (92%). The median operative time was 104 min (IQR, 86–146). Additional procedures were limited to a Heller myotomy in the newly diagnosed achalasia patient. There were no major complications or mortality related to the procedure. The median hospital stay was 2 days (1–4).

At a median follow-up of 22 months (IQR, 8–32) dysphagia was relieved in 16/19 (84%) and bloating was relieved in all 6 patients (Table 3). Of the 3 patients with persistent dysphagia, 2 experienced relief following endoscopic dilation. The GERD-HRQL was obtained in 22 patients (88%) after the conversion and showed a median score of 5 (IQR, 3–13). Occasional use of anti-reflux medication was reported by 8 patients (32%). Two patients (8%) developed significant reflux requiring a redo-Nissen fundoplication. Patient-reported overall health was satisfied in 60% (n = 15), neutral in 24% (n = 6), and dissatisfied in 16% (n = 4). Overall, 92% of patients (n = 23) were satisfied with their postoperative symptom relief.

Table 3 Clinical and symptomatic outcomes
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Discussion

Laparoscopic fundoplication represents the gold standard in the surgical treatment of GERD. In the USA, the Nissen fundoplication as the classic 360-degree posterior wrap is the most commonly performed type of fundoplication as it is believed to provide the best reflux control.4 Postoperative adverse effects include dysphagia, bloating, and the inability to belch. These side effects are usually self-limited not requiring therapy. If the symptoms are due to mechanical issues like a slipped or disrupted wrap or a recurrent hiatal hernia, it will require a reoperation with a redo-Nissen fundoplication to restore the correct function and anatomy of the wrap.9 However, protracted dysphagia and gas-bloat syndrome without anatomical reason occur in approximately 2–20% and up to 30%, respectively, and require therapy.10–13,14,15

An alternative to a Nissen fundoplication is a partial 270° posterior wrap or Toupet fundoplication. In contrast to the USA, many countries consider this type of wrap equivalent to the Nissen fundoplication. Several randomized clinical trials have shown effective reflux control with lower postoperative side effects after Toupet compared to Nissen fundoplication. Persistent dysphagia and gas-bloat syndrome are reported to occur in approximately 0–8 and 0–25%, respectively.5,16,17 There is an ongoing debate on the optimal type of fundoplication. While some authors fear the partial wrap to represent an undertreatment in severe GERD cases, others point out that higher postoperative dysphagia rates after Nissen fundoplication could be prevented by the Toupet procedure.

There is no clear consensus on the optimal type of fundoplication; however, Toupet fundoplication is the treatment of choice in patients with esophageal motility abnormalities to prevent postoperative dysphagia.18 Of note, in our series, 56% of patients suffered from esophageal motility abnormalities prior to Nissen fundoplication and conversion to Toupet led to good dysphagia and bloating relief. Thus, careful preoperative assessment of esophageal function by high-resolution manometry and or video esophagram is paramount in all GERD patients to prevent postoperative dysphagia.

The management of chronic post-Nissen dysphagia and gas-bloat syndrome in patients with no evidence of an anatomical reason is challenging. Treatment options are limited and no standardized therapy approach is defined. In fact, its management relies on level 4 evidence (expert opinion) at best.9 One therapy option is endoscopic dilation but data on outcomes are extremely limited. Varying among studies, dysphagia was reported to resolve in up to 50–67%.19,20 However, a considerable number of patients require multiple dilations and the literature is limited to small case series.19–21 Patients with postoperative difficulty swallowing who had undergone more than one anti-reflux surgery were found to respond less well to endoscopic dilation.19 Experience with Botox injections in the setting of post-Nissen dysphagia is largely anecdotal. Also, therapy recommendations for bloating syndrome following fundoplication are weak ranging from lifestyle modifications as diets, slow eating, and smoking cessation to the intake of gas-reducing or prokinetic drugs.

Conversion to Toupet fundoplication is a logical treatment approach for Nissen-patients with protracted side effects since primary Toupet fundoplication results in low postoperative dysphagia and bloating rates. Skinner et al. reported that some patients benefit from revision from a total to a partial wrap.22 However, literature on results of conversion is scant and mostly limited to outcomes after revisional anti-reflux surgery in general. These procedures are associated with poorer outcomes and should therefore only be performed by experienced surgeons at high-volume centers.23 Thus, the benefit of conversion from total to partial fundoplication remains unknown.24,25 Richter J. reported in his review from 2013 that patients suffering from protracted postoperative dysphagia who fail to respond to dilations will finally have to undergo conversion to a partial wrap. He also described conversion as final treatment option for severe gas-bloat syndromes after failure of conservative methods.26

Bais et al.27 analyzed the effects of conversion to a 270° wrap on esophageal sphincter dynamics in patients with persistent dysphagia following Nissen fundoplication. In his study of 18 patients, conversion led to complete resolution of dysphagia in 10 patients and mild intermittent dysphagia in the remaining 8 patients. A decrease in lower esophageal sphincter (LES) residual relaxation pressure to below 5 mmHg was seen in all patients with resolution of dysphagia following conversion to a partial wrap. In 2011, a small case series of conversions (n = 6) was published by the Mayo Clinic, Rochester. The study was limited to short-term outcomes and focused more on the surgical technique rather than postoperative symptom relief and reflux control.28 Their findings were similar to ours as all patients experienced improvement in dysphagia with complete resolution of dysphagia and good reflux control in 4 patients (67%). Since the Toupet fundoplication certainly shows benefits as revisional technique, it has to be mentioned again that several authors recommend the performance of a partial wrap as primary anti-reflux surgery to prevent postoperative dysphagia.

Our series is the largest to our knowledge to investigate the effect of conversion from Nissen to Toupet fundoplication on refractory postoperative dysphagia or gas-bloat syndrome. Our study shows that conversion is effective in relieving refractory dysphagia and gas-bloat syndrome in 84 and 100%, respectively. Conversion was completed laparoscopically in 92% of patients without any intraoperative or postoperative complications. Twenty-three of 25 patients (92%) experienced satisfying symptom relief without reflux recurrence while only 2 patients required reoperation for persistent reflux.

Conclusion

Post-Nissen dysphagia and gas-bloat syndrome without an anatomical correlate occur in approximately 10%. Conversion of Nissen to Toupet fundoplication relieves dysphagia in 84% and bloating in 100% without significant rate of GERD recurrence. Given the absence of serious complications, conversion should be considered in patients with severe ongoing bloating or dysphagia after Nissen fundoplication.