Abstract
Dysphagia after laparoscopic Nissen fundoplication (LNF) is commonly attributed to edema and/or improperly constructed wraps, and in some instances the cause can be difficult to identify. We report, for the first time, the development of secondary achalasia after LNF as a cause of late-onset postoperative dysphagia. A total of 250 consecutive patients undergoing LNF were analyzed for the development of postoperative dysphagia at a university hospital. Patients were considered to have secondary achalasia if they met the following four criteria: (1) preoperative manometry demonstrating normal peristalsis and normal lower esophageal sphincter (LES) relaxation; (2) lack of esophageal peristalsis on postoperative manometry or fluoroscopy with or without incomplete LES relaxation; (3) no mucosal lesions seen on endoscopy; and (4) dysphagia refractory to dilatation. The following three groups of patients were identified: patients who developed secondary achalasia (group A, n = 7); patients with persistent dysphagia requiring and responding to postoperative dilatation (group B, n = 12 patients); and patients whose postoperative recovery was not complicated by dysphagia (group C, n = 231). The groups were comparable in terms of all preoperative variables except for age. Patients in group A were older than those in group B (57 years [range 27 to 66 years] vs. 36.5 years [range 27 to 63 years], P = 0.028) but were not significantly older than patients in group C (45 years [range 20 to 84 years], P = 0.42). The onset of severe dysphagia was later in group Athan in group B (135 days [range 15 to 300 days] vs. 20 days [range 9 to 70 days],P = 0.002). The median weight loss in group A was also significantly greater than in Group B (15 pounds [range 11 to 44 pounds] vs. 4 pounds [range 0 to 15 pounds], P = 0.0007). Two patients in group A who underwent reoperation failed to improve. Botulinum toxin injections were tried in two patients and Heller myotomy in one with good results. Nine patients in group B improved promptly after one dilatation, and three improved after two dilatations. Secondary achalasia should be considered as one of the causes of persistent dysphagia after an apparently successful antireflux operation. Secondary achalasia tends to occur in older patients and is characterized by a delayed onset of symptoms. Imaging studies are a reliable means of excluding mechanical obstruction as a cause of secondary achalasia, and a negative result should raise the suspicion of secondary achalasia. Esophageal motility studies are necessary to confirm the diagnosis. Failure to consider the diagnosis of secondary achalasia can lead to multiple fruitless attempts at dilatation or even inappropriate reoperations.
Similar content being viewed by others
References
Watson DI, Jamieson GG, Mitchell PC, Devitt PG, Britten-Jones R. Stenosis of the esophageal hiatus following laparoscopic fundoplication. Arch Surg 1995;130:1014–1016.
Devitt PG, Watson DI, Kennedy A, Game PA, Jamieson GG. Posterior versus anterior hiatal repair during laparoscopic Nissen fundoplication: A randomised controlled trial. Aust N Z J Surg 1999;69:57–58.
Hunter JG, Smith CD, Branum GD, WaringJP, Trus TL, Cornwell M, Galloway K. Laparoscopic fundoplication failures: Patterns of failure and response to fundoplication revision. Ann Surg 1999;230:595–606.
Soper N, Dunnegan D. Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann Surg 1999;229:669–677.
Horgan S, Pohl D, Bogetti D, Eubanks T, Pelligrini C. Failed antireflux surgery: What have we learned from reoperations? Arch Surg 1999;134:809–817.
Low DE, Mercer CD, James EC, Hill LD. Post Nissen syndrome. Surgery 1988;167:1–5.
Earlam RJ, Ellis FH Jr, Nobrega FT. Achalasia of the esophagus in a small urban community. Mayo Clin Proc 1969;44:478–483.
HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, Maryland. http://www.ahrq.gov/data/hcup/hcupnet.htm
Grimson KS, Baylin CJ. Transthoracic vagotomy. JAMA 1947;134:925–932.
Carter SL. Resolution of postvagotomy dysphagia. JAMA 1978;240:2656–2657.
Sharp JR. Mechanical and neurogenic factors in postvagotomy dysphagia. J Clin Gastroenterol 1979;1:321–324.
Greatorex RA, Thorpe JA. Achalasia-like disturbance of oesophageal motility following truncal vagotomy and antrectomy. Postgrad MedJ 1983;59:100–103.
Spencer JD. Postvagotomy dysphagia. Br J Surg 1975;62:354–355.
Moses WR. Critique on vagotomy. N Engl J Med 1947;237:603–608.
Postlethwait RW, Kim SK, Dillon ML. Esophageal complications of vagotomy. Surg Gynecol Obstet 1969;128:481–488.
Harris J, Miller CM. Cardiospasm following vagotomy. Surgery 1960;47:568–570.
Wilcox RS. Cardiospasm following vagotomy. Am J Surg 1950;72:843.
Pierandozzi JS, Ritter JH. Transient achalasia. A complication of vagotomy. Am J Surg 1966;111:356–358.
Guelrud M, Zambrano-Rincones V, Simon C, Gomez G, Salinas A, Toledano A, Rudick J. Dysphagia and lower esophageal sphincter abnormalities after proximal gastric vagotomy. Am J Surg 1985;149:232–235.
Edwards DA. Post-vagotomy dysphagia. Lancet 1970;1:90–92.
Suleiman SI, Maglad SA, Hobsley M. Dysphagia following selective vagotomy. Br J Surg 1979;66:607–608.
Sapounov S, Sraieb R. Rare complications after selective vagotomy and pyloroplasty. Gastroplegia and achalasia of the cardia. J Radiol Electrol Med Nucl 1972;53:657–660.
Wirthlin LS, Malt RA. Accidents of vagotomy. Surg Gynecol Obstet 1972;135:913–916.
Duntemann TJ, Dresner DM. Achalasia-like syndrome presenting after highly selective vagotomy. Dig Dis Sci 1995;40:2081–2083.
Ellingson TL, Kozarek RA, Gelfand MD, Botoman AV, Patterson DJ. Iatrogenic achalasia. A case series. J Clin Gastroenterol 1995;20:96–99.
Parrilla P, Aguayo JL, Martinez de Haro L, Ortiz A, Mar-tinez DA, Morales G. Reversible achalasia-like motor pattern of esophageal body secondary to postoperative stricture of gastroesophageal junction. Dig Dis Sci 1992;37:1781–1784.
Yeoman LJ, Grundy A, Parker MC, Fiennes AG. Pseudoachalasia after radical gastrectomy. Br J Surg 1989;76:97–98.
Poulin EC, Diamant NE, Kortan P, Seshadri PA, Schlachta CM, Mamazza J. Achalasia developing years after surgery for reflux disease: Case reports, laparoscopic treatment, and review of achalasia syndromes following antireflux surgery. J Gastrointest Surg 2000;4:626–631.
Reynolds JC, Parkman HP. Achalasia. Gastroenterol Clin North Am 1989;18:223–255.
Little AG, Correnti FS, Calleja IJ, Montag AG, Chow YC, Ferguson MK, Skinner DB. Effect of incomplete obstruction on feline esophageal function with a clinical correlation. Surgery 1986;100:430–436.
Mattox HE III, Albertson DA, Castell DO, Richter JE. Dysphagia following fundoplication: "Slipped" fundoplication versus achalasia complicated by fundoplication. Am J Gastroenterol 1990;85:1468–1472.
O’Brien CJ, Collins JS, Collins BJ, McGuigan J. Aperistaltic oesophageal disorders unmasked by severe post-fundoplication dysphagia. Postgrad Med J 1990;66:1047–1049.
Katz PO, Richter JE, Cowan R, Castell DO. Apparent complete lower esophageal sphincter relaxation in achalasia. Gastroenterology 1986;90:978–983.
Vantrappen G, Janssens J, Hellemans J, Coremans G. Achalasia, diffuse esophageal spasm, and related motility disorders. Gastroenterology 1979;76:450–457.
Mearin F, Malagelada JR. Complete lower esophageal sphincter relaxation observed in some achalasia patients is functionally inadequate. Am J Physiol Gastrointest Liver Physiol 2000;278:376–383.
Aliperti G, Clouse RE. Incomplete lower esophageal sphincter relaxation in subjects with peristalsis: Prevalence and clinical outcome. Am J Gastroenterol 1991; 86:609–614.
Hirano I, Tatum RP, Shi G, Sang Q, Joehl RJ, Kahrilas PJ. Manometric heterogeneity in patients with idiopathic achalasia. Gastroenterology 2001;120:789–798.
Swanstrom L, Wayne R. Spectrum of gastrointestinal symptoms after laparoscopic fundoplication. Am J Surg 1994;167:538–541.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Stylopoulos, N., Bunker, C.J. & Rattner, D.W. Development of achalasia secondary to laparoscopic Nissen fundoplication. J Gastrointest Surg 6, 368–378 (2002). https://doi.org/10.1016/S1091-255X(02)00019-7
Issue Date:
DOI: https://doi.org/10.1016/S1091-255X(02)00019-7