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Is the use of a bougie necessary for laparoscopic Nissen fundoplication?
Yuri W Novitsky1, Kent W Kercher, Mark P Callery
1Department of Surgery, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655, USA. novitsky@ummhc.org
Hypothesis:
Esophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) is commonly used to prevent an excessively tight wrap. However, a bougie may cause intraoperative gastric and esophageal perforations. We hypothesized that LNF is safe and effective when performed without a bougie.
Design:
Retrospective review of 102 consecutive patients who underwent LNF without a bougie.
Setting:
Tertiary care university hospital.
Patients:
All patients presented with symptoms of reflux disease. Mean (+/- SD) percentage of time with pH of less than 4 was 12.6% +/- 9.4%. Mean DeMeester score was 47.8. Mean (+/- SD) resting lower esophageal sphincter pressure was 15.0 +/- 9.4 mm Hg. Mean (+/- SD) distal esophageal amplitude was 69.4 +/- 39.2 mm Hg.
Intervention:
During LNF, we obtained 2 to 3 cm of intra-abdominal esophagus, divided all short gastric vessels, reapproximated the crura, and performed a loose 360 degrees fundoplication without a bougie.
Main Outcome Measures:
Postoperative rates of dysphagia, gas bloat, and recurrent reflux.
Results:
In the early postoperative period, 50 patients (49.0%) complained of mild, 11 (10.8%) of moderate, and 7 (6.9%) of severe dysphagia. Average (+/- SD) duration of early dysphagia was 4.6 +/- 2.1 weeks. Dysphagia resolved in 61 (89.7%) of 68 patients within 6 weeks. Late resolution of dysphagia was noted in 4 (5.8%) patients. Three patients were successfully treated with esophageal dilatations. Persistent dysphagia was found in 1 patient. Thirty patients (29.4%) had transient gas bloat. Mild persistent reflux, requiring daily medication, was noted in 5 (4.9%) patients.
Conclusions:
Performance of LNF without a bougie offers a safe and effective therapy for gastroesophageal reflux disease. While avoiding the potential risks for gastric and esophageal injury, it may provide low rates of long-term postoperative dysphagia and reflux recurrence.