Clinical and functional factors influencing the outcome of laparoscopic Nissen fundoplication.

Objective: laparoscopic Nissen fundoplication (LNF) is the gold standard of antireflux surgery. Up to 30 % of patients experience symptoms after surgery, with insufficient information available. The main objective was to evaluate epidemiological, clinical, and functional factors associated with symptoms after LNF.

Methods: a retrospective case-control study was performed of 79 operated patients (2015-2024). The relationship between epidemiological data, functional tests, and imaging study results with the occurrence of symptoms after LNF was assessed.

Results: twenty-four asymptomatic and 55 symptomatic patients were included. Functional and imaging tests were normal in the majority of asymptomatic patients. integrated relaxation pressure over 4 seconds (IRP-4s) (95th percentile) in asymptomatic patients was 20.4 mmHg. Female gender (OR 4, 95 % CI: 1.1-14), preoperative dysphagia (OR 8.2, 95 % CI: 1.4-47.6), and IRP-4s (OR 1.2, 95 % CI: 1-1.3) were independent factors for postoperative dysphagia. Type III esophagogastric junction morphology on high-resolution manometry (OR 6.1, 95 % CI: 2.1-18.1) was independently associated with gastroesophageal reflux disease (GERD) symptoms. Acid exposure time (AET) showed a trend toward being an independent factor but did not reach statistical significance (OR 1.1, 95 % CI: 1-1.3). Hiatal hernia in the esophagogram was associated with reintervention (OR 5.5, 95 % CI: 1.6-19.1).

Conclusions: asymptomatic patients mostly have normal functional tests after LNF, although IRP-4s normal value (95th percentile) is higher than proposed in the Chicago classification. Preoperative dysphagia and female gender are independent factors for postoperative dysphagia, which should be considered in the preoperative assessment. Functional and imaging tests are essential in evaluating patients with postoperative symptoms. Dysphagia is associated with higher IRP while GERD symptoms are related to type III esophagogastric junction (EGJ) on high resolution manometry (HRM). Similarly, a hiatal hernia on the esophagogram is associated with reintervention.