Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett’s esophagus?

Objective: to evaluate esophageal dysmotility (ED) and the extent of Barrett’s esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. Methods: twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. Results: sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). Conclusion: LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED.


INTRODUCTION
Esophageal dysmotility (ED) is a motor disorder to be sought and well evaluated before performing anti-reflux surgery 1 . ED can be found in patients with gastro-esophageal reflux disease (GERD) 2,3 and Barrett's esophagus (BE) [4][5][6] .
Increasing evidence indicates that there may be a direct impact of reflux on the inhibitory and excitatory intramural neurons that regulate both peristaltic function and the strength of the esophageal contraction amplitude [7][8][9] .
The most frequent esophageal motility disorders found in BE and GERD patients are lower esophageal sphincter (LES) hypotonia, ineffective esophageal motility (IEM), diffuse esophageal spasm (DES), esophageal body (EB) hypomotility and aperistalsis [3][4][5] . However, BE can also be a consequence of an already manifested ED, with an increase in the reflux of acid and bile salt content into the esophagus when there are impairments in the esophageal clearance, thus contributing to the development of BE [10][11][12] , in a vicious cycle of inflammation and impaired motility leading to a more severe disease 13 .
BE is described as the presence of a extension of salmon-colored mucosa into the tubular esophagus that extends ≥1 cm proximal to the gastroesophageal junction (GEJ) via an upper gastrointestinal (GI) endoscopy, and histopathological examination shows columnar metaplastic epithelium, containing intestinal goblet cells (intestinal metaplasia) [14][15][16] . Despite there being only a few symptoms referred, most patients with BE initially complain of having only symptoms associated with persistent GERD, such as regurgitation and heartburn 17 . When the GERD symptoms are associated with dysphagia, or prior to an anti-reflux surgery, an esophageal manometry (EM) examination is a requirement for proper identification and diagnosis 18,19 .

A B S T R A C T A B S T R A C T
Objective: to evaluate esophageal dysmotility (ED) and the extent of Barrett's esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. Methods: twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. Results: sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). Conclusion: LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED. Laparoscopic Nissen fundoplication (LNF) has been proposed for patients with GERD and BE as an effective and safe therapeutic alternative, especially in cases where inadequate control of reflux symptoms is found during clinical treatment [20][21][22] . Although this may be true, there is still insufficient data related to the changes in esophageal motility and its evolution after surgical treatment of GERD and BE [23][24][25] . However, when successful, LNF provides less exposure to acid and bile salt content, reducing esophageal erosion and, consequently, diminished the metaplastic process present in BE 26,27 .
The aim of the present study is to evaluate esophageal dysmotility and the extent of BE before and after LNF in patients previously diagnosed with BE and ED.

Study design
This study was carried out at the Clinics   Table 1).

DISCUSSION
It is common knowledge that a clinically successful fundoplication is capable of providing satisfactory control of duodenal-gastro-esophageal reflux 26 . However, the timing for indication of this surgical procedure, for patients with BE and ED, is still a challenge 31 .
In our study, we observed a reduction in BE length, from 4.09 cm (± 2.50) preoperatively to 3.91 cm In addition, our data also showed a tendency