High-resolution Manometry Findings in Symptomatic Post-nissen Fundoplication Patients with Normal Endoscopic Configuration

Se Ryung Yamamoto, Tommy H Lee, Kalyana C Nandipati, Pradeep Pallati, Kush R Lohani, Sumeet K Mittal. Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska.

Aim: The aim of this study was to investigate high-resolution manometry findings in symptomatic post-fundoplication patients with normal endoscopic configuration.

Methods: A retrospective review of a prospectively maintained database was conducted to identify patients who underwent HRM after Nissen Fundoplication between September 2008 and December 2012. Patients who also had an endoscopic assessment are included in the study. Patients with endoscopic abnormalities (recurrent hiatal hernia, disrupted, twisted or slipped fundoplication, or esophageal stricture) or patients who underwent collis gastroplasty were excluded. Contrast study and 24-hr pH study if done (n=28) were also reviewed. Symptoms were graded using a standard questionnaire with symptoms graded on a scale of 0-3. Symptom grade 2 or 3 was considered as significant symptom.

Results: One hundred eighty two patients who had Nissen fundoplication underwent HRM during the study. Of 182 patients, 139 patients were excluded (51 had recurrent hiatal hernia, 2 had disrupted fundoplication, 68 had slipped fundoplication, 10 had twisted fundoplication, 2 had esophageal stricture, 3 had no endoscopic assessment, and 3 had collis gastroplasty. Forty-three patients met inclusion criteria (mean age of 56.0 ± 14.8, 32 females). The most common symptom was dysphagia (67%). Patients with dysphagia had a significantly longer length of lower esophageal sphincter (LES) and a higher IRP than patients without dysphagia (p=0.020, 0.049). Furthermore, patients who had a shorter LES (≤ 2 cm) were less likely to have significant dysphagia. Twenty-three patients (60 %) had heartburn. There was no significant difference in HRM findings between patients with and without heartburn. Only 4 of 28 patients showed an abnormal DeMeester score (> 14.7) and there was no correlation between the results of the pH study and lower esophageal sphincter pressure, lower esophageal sphincter pressure integral, and IRP. On multivariate logistic regression analysis, the length of the LES (odds ratio=10.6; 95% CI, 1.8-60.6; p=0.008) and delayed esophageal emptying on contrast study (odds ratio=21.6; 95% CI, 2.3-198.6; p=0.007) were associated with dysphagia. There was no HRM parameter associated significantly with heartburn.

Conclusions: A longer length of the LES and delayed esophageal emptying are associated with dysphagia in patients who had intact Nissen fundoplication. The ideal Nissen fundoplications should be short in length and maintain a near-physiologic IRP.

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