Examining the role of Preoperative Ineffective Esophageal Motility in Laparoscopic Fundoplication Outcomes

Tyler Hall, Natalie Warnes, Kristine Kuchta, Herbert Hedberg, MD, John G Linn, MD, Stephen P Haggerty, MD, Woody Denham, MD, Michael Ujiki, MD. NorthShore University HealthSystem

Introduction: Patients suffering from gastroesophageal reflux disease (GERD) may elect to undergo antireflux surgery (ARS). Our aim was to compare postoperative quality of life outcomes between patients who did and did not exhibit ineffective esophageal motility (IEM) before undergoing laparoscopic fundoplication.

Methods and Procedures: A retrospective review of a prospectively maintained database identified patients who underwe?nt laparoscopic fundoplication between 2009 – 2016. All cases were performed by one of four surgeons at a single institution. Laparoscopic Nissen, Toupet, and Dor fundoplications were studied.

All patients underwent preoperative manometry. Cohorts were defined according to % ineffective clearance reported in manometry results; the first cohort is considered ‘normal’, with less than30% ineffective clearance. The second, third and fourth cohorts exhibited IEM with ≥30%, ≥50%, and 100% ineffective clearance respectively. Quality of life outcomes were measured using Short Form-36 (SF-36), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), Dysphagia scores, and Reflux Severity Index (RSI) surveys administered preoperatively and at 3 weeks, 6 months, 1 year, and 2 years postoperatively. Comparisons between cohorts were made using Fisher’s Exact and Wilcoxon Rank-Sum tests.

Results: A cohort of 282 patients underwent ARS between 2009 – 2016 and agreed to participate in the study. Demographic variables including gender, BMI, and smoking status were similar between all cohorts. Patients with 30%, 50%, and 100% ineffective clearance were more likely to receive a Toupet vs a Nissen fundoplication (Table 1). A higher percentage of patients with effective clearance underwent concurrent hiatal hernia repair, and the distribution of hernia type varied between cohorts (Table 2). There were no significant differences in complications or recurrence rates. Preoperative quality of life measures did not vary between the cohorts nor did postoperative scores at three weeks or six months. Patients with 100% ineffective clearance exhibited worse GERD-HRQL scores one and two years postoperatively (1 year – effective: 5.6, 100% ineffective: 8.5 p = 0.045, 2 years – effective: 7.4, 100% ineffective: 11.0 p = 0.046). Likewise, patients with 30% ineffective clearance showed worse GERD-HRQL scores at one year (effective: 5.6, >30% ineffective: 9.5 p = 0.036).

Conclusion: Preoperative ineffective esophageal motility was shown to result in comparable short-term quality of life following ARS. However, GERD-HRQL scores at one and two yearsshowed worse outcomes in patients with preoperative IEM.