Dessislava I Stefanova, MD, Timothy M Ullmann, MD, Adham Elmously, MD, Katherine D Gray, MD, Jessica N Limberg, MD, Thomas J Fahey III, MD, Felice H Schnoll-Sussman, MD, Philip O Katz, MD, Rasa Zarnegar, MD. NYP-Weill Cornell Medical Center
Introduction: Anti-reflux surgery involves augmentation of the lower esophageal sphincter (LES), however to date little is known about intraoperative changes in LES pressures. Moreover, there is lack of data on the effects of mesh on LES pressure. As such, it is critical for surgeons to maintain a balance between too much and too little augmentation of the LES in order to resolve reflux without causing dysphagia. We hypothesized that dynamic intraoperative LES monitoring may assist in determining the effects of essential steps in anti-reflux surgery.
Methods: Patients with type II/III hiatal hernias undergoing an anti-reflux procedure were enrolled in a prospective database. All operations were performed using robotic-assisted laparoscopic technique with biosynthetic mesh reinforcement of the hiatus using a keyhole technique. Repair was determined on a per-patient basis based on preoperative manometric and clinical characteristics. Intraoperative LES measurements were collected using EndoFlip, which utilizes planimetry impedance, to measure cross-sectional area, pressure, and distensibility of the LES. Correct positioning was ensured by intraoperative visualization and wave narrowing on the EndoFlip display. Data were collected at four crucial timepoints: pre-repair, post hiatal hernia closure, post mesh placement, and post-fundoplication or magnetic augmentation.
Results: A total of 35 patients were included; seventeen patients (48.6%) were female with a mean age of 55.5 years (range 20-86 years). The median preoperative DeMeester score was 32.9 (IQR 19-60). The cohort underwent Nissen (45.7%), Toupet (42.9%), or LINX (11.4%) procedures. Five enrolled patients (14.2%) had previous anti-reflux surgery.
Cross-sectional area (CSA) of the LES decreased significantly following closure of the hiatus (50 [IQR 37-66 mm2] vs. 31 [IQR 24-42.5 mm2], p=0.0003) and remained relatively unchanged thereafter, while pressure increased incrementally from induction to augmentation (25.7[IQR 21.5-33.2 mmHg] vs 40[IQR 35.6-44.1 mmHg], p<0.0001) (See Figure). Distensibility of the LES significantly decreased from pre- to post- fundoplication/augmentation (1.9 mm2/mmHg [IQR 1.3-2.5 mm2/mmHg] vs. 0.8 mm2/mmHg [IQR 0.56-1 mm2/mmHg], p<0.0001).
Mesh placement did not significantly alter cross-sectional area (31[IQR 24-42.5 mm2] vs 29[IQR 23-42 mm2] p=0.32), or pressure (33[IQR 29-36.7 mmHg] vs 35.8[IQR 29-38.7 mmHg], p=0.20).
Discussion: Dynamic intraoperative LES monitoring demonstrated an increase in pressure and a decrease in cross-sectional area and distensibility following fundoplication. Closure of the hiatus produced the most dramatic decrease in LES cross-sectional area, possibly indicating that this plays the most critical component in restoring LES competence. Mesh placement did not significantly change LES parameters. Correlation of these changes with postoperative clinical outcomes is warranted.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94690
Program Number: P520
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster