Background

Post-fundoplication dysphagia is a complex pathology for which accurate diagnosis and effective treatment is often confusing and difficult. Sometimes Achalasia can masquerade as reflux preoperatively and then presents as post-fundoplication dysphagia. Unless there is obvious stricture or slipped fundoplication, tests are often confusing or unhelpful. Our case demonstrates that intraoperative assessment of lower esophageal sphincter (LES) function with Endoflip can help diagnose and treat patients with more precision. Our patient is a 59-year-old female who presented with worsening dysphagia following Toupet fundoplication and hiatal hernia repair. Dysphagia was refractory to balloon dilations and botox injections. Barium swallow and esophagogastroduodenoscopy (EGD) suggested a tight wrap. Endoflip suggested tight LES with poor relaxation and esophageal dysmotility. A diagnostic laparoscopy with intraoperative EGD with EndoFLIP was performed. Intraoperatively, the patient was noted to have a loose hiatus and wrap without slippage of the wrap. EndoFLIP measurements suggested persistent tightness of the LES and a Heller Myotomy was performed to the standard extent. EndoFLIP measurements showed incomplete improvement, however, so the myotomy was extended further onto the stomach. Repeat EndoFLIP findings were improved, indicating the myotomy was now adequate. The patient experienced complete resolution of her symptoms postoperatively. Through intraoperative Endoflip, the appropriate diagnosis was recognized, the appropriate surgery performed, and the appropriate extent of the surgery was ensured, with effective results.