Esophageal Motility Outcome after Nissen Fundoplication: A Systematic Review and Meta-Analysis

Abstract Background: Gastroesophageal reflux disease (GERD) is a very prevalent disease. The Montreal consensus conference in 2006 defined GERD as "a condition which develops when the re-flux of gastric contents causes troublesome symptoms and/or complications". The pathophysiology of GERD is multifactori-al and complex but revolves around an incompetent esophago-gastric junction (EGJ) as an anti-reflux barrier, in the form of transient lower esophageal sphincter relaxations (TLESR) and/ or a hypotensive EGJ. Aim of Study: To evaluate the efficacy of laparoscopic surgeries with regard to esophageal motility and determine a clear indication for these interventions. Additionally, we will compare between preoperative and postoperative manometer results. Patients and Methods: This systematic review and me-ta-analysis was conducted by careful following of the Cochrane handbook for systematic reviews interventions and the results were described according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. The following electronic databases were searched till 2022: Pu-bMed, Medline, Embase, Cochrane Library, Springer link, da-tabases. A manual search was also performed to identify trials in the reference lists of the articles acquired. A search strategy using disease-specific terms (e.g., gastro-esophageal reflux dis-ease), management-specific terms (e.g., laparoscopic antireflux fundoplication), and terms related to surgical procedures (Nis-sen) were adopted. Results: The forest plot meta-analysis shows that Nissen fundoplication significantly reduce the maximum diameter of the EGJ. Also it reduces significantly the cross-section area (CSA) at the EGJ, which means successful fundoplication that permit less refluxate through the EGJ. Also Distensibility in-dex (DI) which can be calculated by dividing the cross-section area of the EGJ (CSA) by the infra-bag pressure at the EGJ. It was found that the distensibility index decreased significantly after Nissen fundoplication than that before fundoplication The decrease of the Distensibility index means more tight fundopli-cation that controlling reflux. Conclusion: This meta-analysis concluded that Nissen fun-doplication increase significantly the LESP which control most of the reflux symptoms as it decreases significantly the regur-gitation and heart burn symptoms. Also, it found that it signifi-cantly decreases the use of proton pump inhibitors and improve life mode of the patient. But it does not significantly change the dysphagia symptoms especially in the early postoperative period. This study promotes much research on the EndoFLIP maneuver during the operation just in the time before insuffla-tion and after performing the wrap as this Endo FLIP assists mostly adjusting the tightness of the wrap.