Noah J Switzer, Anahita D Jalilvand, Monet Mcnally, Alexandra Power, Patricia Belle, Kyle Perry. The Ohio State University
INTRODUCTION: We hypothesized that GERD patients with manometric findings of EJOO on preoperative manometry do not have increased rates of postoperative dysphagia compared to those with normal or hypotensive LES pressures.
With the advent of high-resolution manometry, esophageal dysmotility patterns including functional esophagogastric outflow obstruction (EJOO) have been identified. The optimal management of functional EJOO remains controversial particularly in the setting of concomitant gastroesophageal reflux disease (GERD). There remains a paucity of data regarding the outcomes of laparoscopic Nissen fundoplication (LNF) in this patient population.
METHODS AND PROCEDURES: We tested this hypothesis in a retrospective cohort study of adult patients undergoing LNF for GERD at a large academic medical center between 2009 and 2017. Patients undergoing redo operations and those without the manometric data required to diagnose EJOO or hypertensive LES were excluded. Demographic, preoperative, operative and outcome data were collected and maintained in an IRB approved database. Reflux symptoms and quality of life were assessed using the Gastroesophageal Reflux Symptom Scale (GERSS) and Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaires. Patients were stratified as EJOO if they had an elevated IRP or elevated mean LES residual pressure. Analysis was performed using Stata 14 with a significance level of p<0.05. Data are presented as mean ± SD or median (IQR) as appropriate.
RESULTS: Two hundred and sixteen patients met the study criteria, and 16 (7.41%) met criteria for the EJOO group. There were no differences in patient age, race, weight, or baseline dysphagia rates between groups. Baseline GERD-HRQL (31.0 (22-37) vs. 26 (19-38), p=0.368) and GERSS (40 (28-50) vs. 36 (21-42), p=0.176) scores were similar between control and EJOO patients, respectively. There were no differences in post-operative GERD-HRQL (4 (1-8) vs 3.5 (1-6), p=0.526) or GERSS (6 (1-14) vs 6 (0-10, p=0.616) scores. Dysphagia rates were similar at 6-week (p=0.628) and 1-year follow-up (p=0.359). Three (18.75%) EJOO patients underwent postoperative endoscopic dilation, and none required revision to a partial fundoplication or surgical myotomy.
CONCLUSION: GERD patients with functional EJOO or hypertensive LES achieved similar post-operative outcomes following Nissen fundoplication as patients without elevated LES pressures. However, 18% of patients did undergo endoscopic dilation for postoperative dysphagia. These results suggest that LNF can be safely performed in these patients, but attention should be paid to preoperative dysphagia symptoms and patients should be counselled about potential need for endoscopic dilation after surgery.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95543
Program Number: S045
Presentation Session: Foregut II – Physiology
Presentation Type: Podium
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