Brexton Turner, BS, Melissa Helm, MS, Emily Hetzel, BS, Max Schumm, MD, Jon Gould, MD. Medical College of Wisconsin
Background: Laparoscopic fundoplication is the treatment of choice for medically refractory gastroesophageal reflux disease (GERD). Surgeons seek to create a competent valve at the gastroesophageal junction (GEJ) but are careful to construct a ‘floppy’ fundoplication that is not too tight to minimize potential side effects. The endoscopic functional luminal-imaging probe (EndoFLIPâ) uses impedance planimetry to assess the GEJ intraoperatively. We sought to determine if EndoFLIP variables are associated with symptomatic outcomes following fundoplication.
Methods: This is a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication at a single institution between 2014-2018. All patients met standard indications for GERD surgery and the diagnosis was confirmed based on upper endoscopy or pH/impedance testing. EndoFLIP was used prior to insufflation and following fundoplication intraoperatively. Minimum diameter (Dmin in mm), cross-sectional area (CSA in mm2), intra-bag pressure (in mmHg), and distensibility index (DI in mm2/mmHg) of the GEJ were obtained at 30-mL volumes. GERD Health Related Quality of Life (GERD-HRQL) surveys were administered pre- and postoperatively. Subjects had 6-month, 1 year, or 2-year GERD-HRQL surveys completed. Patients reporting symptoms that were bothersome daily or more frequently were compared to patients without symptoms or who experienced rare symptoms. Receiver operating characteristic (ROC) curves were used to determine if EndoFLIP measurements were correlated with symptomatic outcomes more than 6 months postoperatively.An area under the curve (AUC) greater than 0.700 was considered significant.
Results: 43 patients met inclusion criteria. Using ROC curves, the change in Dmin and CSA measures prior to and following fundoplication were found to be associated with daily or more frequent heartburn at all intervals. A decrease in Dmin of 0.15 mm or less (AUC = 0.718, sensitivity: 71%, specificity: 69%) and a decrease in CSA of 1.5 mm2or less (AUC = 0.728, sensitivity: 71%, specificity: 70%) were predictive of daily or more frequent heartburn. Intra-bag pressure and DI were not predictive of postoperative symptoms (AUC < 0.700).
Conclusions: GEJ opening dynamics attained by EndoFLIP appear to be associated with symptomatic outcomes. When the Dmin and CSA do not decrease by a defined threshold, heartburn is more likely to be problematic at 6 or more months postoperatively. This suggests that the fundoplication may not be tight enough to prevent persistent or recurrent GERD. Validation with pH studies and further study may help to define thresholds and metrics that could help guide the creation of a fundoplication intraoperatively.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93401
Program Number: S043
Presentation Session: Foregut II – Physiology
Presentation Type: Podium