Severe dysphagia after laparoscopic fundoplication: usefulness of barium meal examination to identify causes other than tight fundoplication--a prospective study.

Background. The aim of this study was to determine the results of a barium meal examination after laparoscopic wrap in symptomatic patients (SPs) with no upper endoscopic anomalies and no increase in inferior esophageal sphincter pressure (SPs). Radiologic results were compared with results from patients with no symptoms (ASPs) and were compared with the surgical findings in patients who underwent reoperation. Methods. Twenty SPs were included 27 +/- 6 months after a total wrap (n = 13 Nissen procedures) or a posterior wrap (n = 7 Toupet procedures) performed in several hospitals in Haute Normandie. All patients had severe symptomatic dysphagia with epigastric pain (n = 18 patients) and/or marked weight loss (n = 16 patients). Control subjects were 31 consecutive ASPs within our center who were prospectively included 4 +/- 1 months after a Nissen (n = 6 patients) or a Toupet (n = 25 patients) procedure. A barium meal examination was performed in all patients and interpreted by 3 independent observers who knew that the patients had undergone a wrap but who did not know whether the patients had symptoms. Fifteen of the 20 SPs underwent a second operation. Results. Barium meal examination was more often abnormal in SPs than in ASPs (17/20 vs 4/31 patients; P <.001), whichever the type of wrap. Two abnormal radiologic results were observed in both groups: an esophageal barium level and an esogastric plication. Only a high barium level in the esophagus was more frequently observed in SPs than in ASPs (P <.05). Three radiologic results were specifically observed in SPs: a long cardial narrowing beginning above the wrap, a mediogastric plication, and a gastric volvulus. A comparison of radiologic anomalies and surgical findings showed that (1) a radiologic long cardial narrowing was explained by fibrotic stenosis of the muscular esophageal hiatus (n = 6 patients), (2) a mediogastric plication (n = 4 patients) was due to gastric volvulus (n = 3 patient) or to gastric wrap (n = 1 patient), and (3) results of volvulus (n = 5 patients) indicated a gastric volvulus. Additional surgical procedures resulted in the disappearance of symptoms in 13 of 15 patients. Conclusions. After laparoscopic fundoplication when upper endoscopy and esophageal manometry are normal, results of a barium meal examination can explain the cause of dysphagia in almost all patients. Three radiologic results were specific for SPs and indicated major morphologic disturbances that could not be treated by endoscopic dilation but that could be treated by additional surgical procedures.