Severe Intermittent Dysphagia is not a Contraindication for Total Nissen Fundoplication

Aim: To study the effect of total Nissen fundoplication on severe intermittent esophageal dysphagia according to a hiatal hernia. Methods: Twenty-three consecutive patients (12 men, 11 women, median age 43 yrs) with severe intermittent dysphagia and with hiatal hernia verified by endoscopy were included in the study. They were investigated with esophageal high-resolution manometry (HRM)-, and 24-hr pH- monitoring prior to hiatal hernia repair and at follow-up 6 months after surgery. On both test occasions, the patients were asked to fill in a questionnaire comprising 17 questions on esophageal and chest symptoms (severity grades 0-3). Results: A hiatal hernia was recorded via HRM in all 23 patients prior to surgery and in no one at follow-up. Prior to surgery, all patients had either severe no stenotic dysphagia or frequent retention symptoms in the chest while eating. These two mechanical problems were relieved by surgery (p< 0.0001). Motility disturbances in the distal esophagus were recorded in 35 % of patients prior to surgery, but in no one at follow-up. The median total reflux time prior to surgery was 2.2 % (range 0.2 – 36.5 %) and at follow-up 0 % (0 – 0.3 %). Five patients had no pathological gastro-esophageal reflux prior to surgery. Conclusion: Severe intermittent esophageal dysphagia in hiatal hernia patients can be successfully treated with total Nissen fundoplication, and this should be a strong indication for hiatal hernia surgery even in the absence of pathological gastro-esophageal reflux.