Abstract
Nissen fundoplication (NF) is one of the most common anti-reflux surgeries (ARS) performed worldwide for gastro-oesophageal reflux disease (GERD). There is a theoretical belief that ineffective oesophageal motility (IEM) can cause increased postoperative dysphagia (POD) following NF due to weak and failed peristalsis against a 360-degree wrap. There is scarce evidence to support the hypothesis that NF in pre-existing ineffective oesophageal motility causes increased POD. This study aims to identify the impact of preoperative IEM on POD following NF. In this study, based on the PRISMA guidelines, we conducted a systematic search for articles published in PubMed, Scopus, EMBASE, as well as in the Cochrane Library, using the search terms "ineffective oesophageal motility", "motility disorder and fundoplication", "Esophageal hypomotility", "Ineffective esophageal motility and GERD" from the inception of these databases to an end date of September 22, 2025. The study participants included patients who had NF for GERD and who had pre-existing IEM. These patients were compared with NF patients with normal motility or non-IEM patients. The outcome measured was POD following NF. The odds ratio and its 95% confidence interval were calculated using the random-effects model. A sensitivity analysis was performed to assess heterogeneity within the study population. For publication bias funnel plots and risk of bias assessment in randomised controlled trials, the Risk of Bias 2 (RoB) is used. For non-randomised studies, the Newcastle-Ottawa Scale (NOS) score is employed. A total of 10 articles were identified in the search, involving 1473 patients, of whom 1093 had undergone Nissen fundoplication. Among these 1093 patients, 427 had pre-existing IEM. The forest plot in this study suggests that there is no statistical significance in the POD between IEM and non-IEM patients following NF (P = 0.30, Odds ratio = 1.20, overall effect Z = 1.04, df = 5, I(2) = 0%, 95% CI 0.82, 1.71). There is no statistically significant improvement in POD in patients with IEM compared with preoperative dysphagia following NF in RCTs. In contrast, observational studies show considerable improvement in POD in patients with IEM following NF. The overall effects yielded a p-value = 0.01, OR = 0.40, 95% CI, overall effect Z = 2.54, I(2) = 73%. Following NF, POD occurred at similar rates in both IEM and non-IEM patients (P = 0.30, OR = 1.2). NF does not worsen the preoperative dysphagia in patients with IEM and GERD. There can be other factors which worsen postoperative dysphagia. In fact, POD has improved following NF in IEM (P = 0.01, OR = 0.40); however, these results are based primarily on observational studies and on heterogeneous data (I(2) = 73%).