A patient undergoes laparoscopic Nissen fundoplication for refractory GERD. Two years later, she presents with progressive dysphagia to solids and liquids, regurgitation, and inability to belch. Barium swallow shows a bird's beak appearance of the distal esophagus. What complication has occurred?
- A Recurrent GERD with peptic stricture
- B Fundoplication wrap migration into the chest
- C Achalasia induced by a too-tight (hypertensive) wrap ✓
- D Esophageal cancer
Explanation
A too-tight Nissen fundoplication can create a functional obstruction at the gastroesophageal junction that mimics achalasia — characterized by dysphagia to both solids and liquids, regurgitation, inability to belch (gas-bloat syndrome), and the characteristic bird's beak appearance on barium swallow due to a tight lower esophageal segment. High-resolution manometry can confirm elevated lower esophageal sphincter pressure and poor esophageal body peristalsis. Management may require esophageal dilation, laparoscopic revision to a looser wrap, or takedown of the fundoplication. This is a recognized late complication of overly tight anti-reflux surgery.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.