Is the Use of a Bougie Necessary for Laparoscopic Nissen Fundoplication?

Abstract

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°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.

Evidence-Based Appraisal of Antireflux Fundoplication

“…111,112 Some authors, therefore, do not recommend its routine use. 113 Looking at the only available RCT, 72 it appears that routine use of a bougie significantly reduces the rate of severe postoperative dysphagia, as defined by the authors, by 13.7%, with a 1.2% risk of iatrogenic perforation (Table 10). On the other hand, if we look at something more clinically relevant, such as the rate of postoperative dilatation, the results were higher in the group treated by routine use of the bougie.…”

Is a bougie required for the performance of the fundal wrap during laparoscopic Nissen fundoplication?

“…However there was no significant difference in the incidence of severe dysphagia as defined as patients requiring further intervention between the two groups. A subsequent retrospective study of 102 patients who underwent a LNF without a bougie reported good results with a low rate of long-term postoperative dysphagia [17]. Only three patients in this study needed oesophageal dilatation for their symptoms.…”

“…Though commonly used, oesophageal intubation has not been critically assessed. There is a wide variation in the size of the bougies used by different surgeons and this does not appear to affect dysphagia rates significantly [17].…”

Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation

“…These fi ndings were similar to the results of Patterson et al 29 . Some authors advocate no advantages by this routine technique 30 , emphasizing the risk for perforation and severe complications related to these tubes 29,31 . We do not use this tube, but we double-check the gastric fundus fl oppy anti-refl ux valve as described previously.…”