Michael A Antiporda, MD1, Christy M Dunst, MD2, Kelly R Haisley, MD1, Walaa Abdelmoaty, MD1, Kevin M Reavis, MD2, Daniel Davila Bradley, MD2, Steven R Demeester, MD2, Lee L Swanstrom, MD3. 1Providence Portland Medical Center, 2The Oregon Clinic, 3Institute for Image Guided Surgery (IHU-Strasbourg)
Introduction: The significance of manometric esophagogastric junction outlet obstruction (EGJOO) in the setting of objective GERD is unknown. Some hypothesize that adding myotomy at the time of fundoplication is beneficial in these patients, particularly those with significant dysphagia. Others worry that myotomy compromises reflux control. The aim of this study is to explore post-operative outcomes in patients treated for GERD plus EGJOO.
Methods: At our institution, the decision to add Heller myotomy for EGJOO in the setting of GERD is per surgeon preference. We retrospectively reviewed all patients who underwent surgery for GERD with concurrent EGJOO (defined as IRP > 15). Objective GERD was defined by abnormal pH testing or endoscopic evidence of erosive esophagitis, or Barrett esophagus. Patients with named hypercontractility disorder, paraesophageal hernia, or prior foregut operation were excluded. Pre-operative objective testing included HRM, EGD, pH study, and UGI. Pre- and post-operative symptoms were assessed via validated questionnaire. Peri-operative variables including operative approach, length of stay, and complications were recorded.
Results: Twenty-seven patients underwent anti-reflux surgery in the setting of elevated IRP from 2013 to 2018 (mean age 57, 37% male, 33% BMI >30). Pre-op HRM revealed mean IRP 19.3 and ineffective esophageal motility in 19%. Median pre-op DeMeester score was 22.2. Pre-op EGD revealed erosive esophagitis or Barrett esophagus in 11 patients. Commonest symptomatic indication was regurgitation (93%) followed by heartburn (82%) and dysphagia to solids (64%). Operative treatment included Heller myotomy in 33%. Complete fundoplication was performed in 52% and partial fundoplication in the remainder. Median length of stay was two days. There were eight complications including two sub-clinical leaks that resolved without additional procedural intervention (one patient had undergone concurrent pyloroplasty and the other underwent concurrent endoscopic cricomyotomy). Surgery resulted in overall improved rates of heartburn, regurgitation, and dysphagia. When stratified by performance or omission of myotomy, there was a trend in the short term towards improved rates of dysphagia (22% vs 33%) and regurgitation (0% vs 11%) but increased persistent pyrosis (22% vs 11%) in the myotomy group, but these were not statistically significant.
Conclusions: Ideal treatment of GERD and EGJOO is unknown. The addition of myotomy may be helpful in patients with primary complaint of dysphagia, and does not itself appear to increase risks of surgery. Tailoring of the anti-reflux operation to address the most troublesome complaint of the patient with GERD and EGJOO may lead to the best overall symptomatic outcome.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94550
Program Number: P503
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster