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Minimal vs. Obligatory Dissection of the Diaphragmatic Hiatus During Magnetic Sphincter Augmentation Surgery: An Intention to Treat Analysis

James M Tatum, MD, Evan Alicuben, MD, Nikolai Bildzukewicz, MD, Kulmeet Sandhu, MD, Kameron Samakar, MD, Caitlin Houghton, MD, John L Lipham, MD. Keck School Of Medicine Of The University Of Southern California

Introduction: Implantation of the magnetic sphincter augmentation device early after its introduction was accomplished with minimal hiatal dissection (MHD) at the diaphragmatic hiatus, dissection only occurring to treat an obvious hiatal hernia. Due to concern of possible MSA device dysfunction if herniated into an occult or small hiatal hernia, in August 2015 our operative procedure changed to obligatory dissection (OD) of the hiatus at the time of all implantations. We hypothesize this will reduce the rates of dysphagia, recurrent GERD and device removal.

Patient and Methods: Between December 2012 and September 2016, 182 patients underwent MSA implant at a single medical center and have complete records available for review through September 2017. The MHD dissection period extended from December 2012 to September 2015, there after all implants were accomplished with intention to dissect the hiatus and close the crura (OD). Data were analyzed using SPSS (SPSS Inc.)

Results: MHD was performed in 62% (112/182) vs OD in 38% (70/182), mean follow up time in days for MHD and OD was 552 (SD 415) vs. 333 (281) days. There were no significant differences in proportion of patients who were male, or in presenting complaints. BMI was significantly lower in MDH vs OD (26.7. vs. 28.2), p=0.02.  Intraoperative measurement of hernia size for the MHD vs OD was 1.25(1.5)cm vs 3.85(2.7)cm,  p<0.001; and crural closure was performed in only 26.8% vs. 88.7%, p<0.001. Size of MSA device implants were smaller in MHD vs OD, 13.7(1.1) vs. 14.7(1.2) beads, p<0.001). At first visit follow up visit there was no difference in patients with dysphagia (p=0.15) or who remained on PPI (0.4). Recurrent GERD (defined as resumption of PPI after successful initial post-operative wean) was significantly lower in patients after OD than they were after MHD, 1.5% vs. 15%, p<0.001. Delayed onset dysphagia (defined as recurrent dysphagia after resolution of initial post-operative symptoms) was 0% in the OD group vs. 7% in the MHD group, p=0.02. Device removal rates are lower affter OD vs. MHD 4.3% vs. 7.2%, p=0.4.

Conclusion: Early results after a change in operative procedure from MHD to an intention to perform OD and accomplish crural approximation in all cases during MSA implantation have decreased rates of recurrent dysphagia and GERD symptoms, despite an increased proportion of patients with larger hiatal hernia and more complex anatomic disease at the time of initial operation.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 88536

Program Number: S049

Presentation Session: Foregut Session

Presentation Type: Podium

18

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