A Case of Postfundoplication Dysphagia without Symptomatic Improvement after Endoscopic Dilatation
A 25-year-old female patient was referred from an outside hospital in November 2011 for the management of dysphagia. The patient initially presented to a different hospital in 2008 with a 4-year history of heartburn and acid regurgitation and was diagnosed with GERD. The patient did not complain of dysphagia or globus symptoms at the time, and the esophagogastroduodenoscopy (EGD) performed at the previous hospital showed grade B erosive esophagitis according to LA classification. A 24-hour intraesophageal pH study showed a DeMeester score of 33.1 (normal value, <14.2), a total fraction time of pH <4 of 9%, and abnormal acid regurgitation when the patient was upright (upright fraction time of pH <4, 24%). Preoperative esophageal manometry showed normal lower esophageal sphincter (LES) relaxation during swallowing (resting LES pressure 14 mm Hg to LES relaxation 2 mm Hg), and no peristalsis was observed in the esophageal body (). A favorable response to medical treatment (proton pump inhibitor) was not achieved, and subsequent laparoscopic Nissen fundoplication was performed in September 2009 in a previous hospital. Thereafter, the patient developed postoperative complications such as solid and liquid dysphagia, a sensation of inability to belch, and a sticking sensation in her lower to mid chest. Approximately 2 to 3 weeks after the operation, the patient's symptoms showed improvement. However, regurgitation recurred and was soon aggravated to dysphagia. Dysphagia was worse with solids than with liquids, and these symptoms occurred whenever the patient swallowed food. Medical therapy with proton pump inhibitors and prokinetics was attempted in the previous hospital but was ineffective. The patient was then referred to our hospital. EGD performed at our hospital showed postfundoplication status, and the endoscope could pass through the gastroesophageal junction without any resistance (). The previously observed erosive esophagitis was improved. Esophageal mucosal biopsies ruled out eosinophilic esophagitis. Abnormal barium stasis in the esophageal body was found on barium esophagography (). A paraesophageal hernia was observed on abdominopelvic computed tomography (), which was performed to evaluate the patient for postoperative organic causes of dysphagia. Esophageal manometry showed aperistalsis in the esophageal body, and the resting pressure and percent relaxation of LES were 5 mm Hg and 81%, respectively, which were within the normal range (). In our hospital, medical treatment (prokinetics, mosapride 15 mg; proton pump inhibitor, esomeprazole 40 mg; calcium channel blocker, nifedipine 5 mg) was initiated and continued for 2 months; however, a favorable outcome was not obtained. Pneumatic dilatation with a 30-mm balloon was used for symptom relief, but the symptoms did not improve. Therefore, additional pneumatic dilation with a 35-mm balloon was performed 2 weeks later. Barium esophagography performed after the second pneumatic dilatation showed improved barium passage through the esophagus, but the solid and liquid dysphagia, and globus sensation symptoms were not improved (). We considered esophageal motility disorder or paraesophageal hernia that developed after fundoplication as the most likely cause of the dysphagia. Therefore, we recommended a revision operation that would involve taking down the wrap or Toupet fundoplication. However, the patient refused to consent to a second operation and is currently undergoing medical treatment.