Pneumatic Balloon Dilation is a Safe and Effective Treatment for Severe Dysphagia Post-Fundoplication

Abstract

Introduction: Fundoplication is a common surgical treatment for refractory gastroesophageal reflux disease or following myotomy for achalasia. Although transient postoperative dysphagia often related to postoperative edema and inflammation is common, the rate of severe or persistent dysphagia lasting more than 3 months is reported 3% to 24% post fundoplication for GERD. Dysphagia recurs in about 10% of cases post successful myotomy and fundoplication. Its pathophysiology is unclear, but esophageal dysmotility or functional obstruction at GE junction due to the wrap may be important. Our aim was to evaluate the efficacy and safety of pneumatic balloon dilation for refractory dysphagia following fundoplication. The role of EndoFLIP study in pre and post dilation was also assessed. Methods: Retrospective review was performed of all patients who underwent pneumatic dilation over 3 years. Patients in whom pneumatic dilation was performed for primary achalasia were excluded. Demographic details, esophageal motility studies, symptoms pre and post dilation, and esophageal imaging studies were reviewed. Results: 10 patients met the inclusion criteria. All patients had fundoplication from 3 to 20 years prior to presentation and had symptoms of dysphagia unresponsive to multiple (>3) Savary or balloon dilations. Mean age was 57.1 years with M/F=3/7. 6 patients had fundoplication with myotomy for achalasia. 4 patients had fundoplication for GERD. All pneumatic dilations were with either 30 mm or 35 mm Boston Scientific Rigiflex balloons performed under fluoroscopy with confirmation of waist obliteration. The esophageal manometry showed elevated IRP and IBP (mean of 20 and 18.4) along with poor bolus transit (mean bolus transit failure of 77%). All patients tolerated the pneumatic dilation well without complications. All had significant symptom improvement shown either with esophageal symptoms scores reduction or post dilation Eckardt scores of <3. 2 patients had EndoFLIP study pre and post pneumatic balloon dilation showing three-fold increase in distensibility index (0.4 to 1.2 and 0.7 to 2.8). Conclusion: Refractory dysphagia post fundoplication is a rare, but disabling complication. In patients who failed bougie dilation, and with proven GE junction functional obstruction (high IRP, low distensibility index), pneumatic balloon dilation appears to be a safe and effective option. High resolution esophageal manometry and EndoFlip assessment are useful tools for assessment and adequacy of treatment.Table: No Caption availableFigure: EndoFLIP evaluation before and after pneumatic balloon dilation.