title: Is the use of a bougie necessary for laparoscopic Nissen fundoplication?
abstract: OBJECTIVE
  Esophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) is commonly used to prevent an excessively tight wrap. However, a bougie may cause intraoperative gastric and esophageal perforations. We hypothesized that LNF is safe and effective when performed without a bougie.
  
  
  METHODS
  Retrospective review of 102 consecutive patients who underwent LNF without a bougie.
  
  
  METHODS
  Tertiary care university hospital.
  
  
  METHODS
  All patients presented with symptoms of reflux disease. Mean (+/- SD) percentage of time with pH of less than 4 was 12.6% +/- 9.4%. Mean DeMeester score was 47.8. Mean (+/- SD) resting lower esophageal sphincter pressure was 15.0 +/- 9.4 mm Hg. Mean (+/- SD) distal esophageal amplitude was 69.4 +/- 39.2 mm Hg.
  
  
  METHODS
  During LNF, we obtained 2 to 3 cm of intra-abdominal esophagus, divided all short gastric vessels, reapproximated the crura, and performed a loose 360 degrees fundoplication without a bougie.
  
  
  METHODS
  Postoperative rates of dysphagia, gas bloat, and recurrent reflux.
  
  
  RESULTS
  In the early postoperative period, 50 patients (49.0%) complained of mild, 11 (10.8%) of moderate, and 7 (6.9%) of severe dysphagia. Average (+/- SD) duration of early dysphagia was 4.6 +/- 2.1 weeks. Dysphagia resolved in 61 (89.7%) of 68 patients within 6 weeks. Late resolution of dysphagia was noted in 4 (5.8%) patients. Three patients were successfully treated with esophageal dilatations. Persistent dysphagia was found in 1 patient. Thirty patients (29.4%) had transient gas bloat. Mild persistent reflux, requiring daily medication, was noted in 5 (4.9%) patients.
  
  
  CONCLUSIONS
  Performance of LNF without a bougie offers a safe and effective therapy for gastroesophageal reflux disease. While avoiding the potential risks for gastric and esophageal injury, it may provide low rates of long-term postoperative dysphagia and reflux recurrence.
authors.affiliation: Department of Surgery, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655, USA. novitsky@ummhc.org
authors.forename: Yuri W
authors.initials: YW
authors.lastname: Novitsky
authors.forename: Kent W
authors.initials: KW
authors.lastname: Kercher
authors.forename: Mark P
authors.initials: MP
authors.lastname: Callery
authors.forename: Donald R
authors.initials: DR
authors.lastname: Czerniach
authors.forename: John J
authors.initials: JJ
authors.lastname: Kelly
authors.forename: Demetrius E M
authors.initials: DE
authors.lastname: Litwin
mesh_terms: D003680:Deglutition Disorders / Q000209:etiology / Q000628:therapy; D004947:Esophagus; D005260:Female; D018662:Fundoplication / Q000295:instrumentation / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D007440:Intubation / Q000295:instrumentation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012008:Recurrence; D012189:Retrospective Studies