Risk Factors for Post-fundoplication Dysphagia: Use of High-resolution Manometry

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: High-resolution manometry (HRM) provides more detailed assessment of esophageal function compared to conventional manometry. The aim of this study was to investigate the relationship between pre-operative HRM findings and post-operative dysphagia after fundoplication.

Methods: A retrospective review of a prospectively maintained database was conducted to identify patients who had pre-operative HRM and underwent primary fundoplication for gastro-esophageal reflux disease between September 2008 and September 2012. Patients who had a large hiatal hernia (> 5cm) were excluded. Pre- and post-operative symptoms were evaluated using a standard questionnaire with symptoms graded on a scale of 0-3.

Results: One hundred and eight patients met the criteria (mean age of 51.4 ± 14.8, 71 females). Eighty-three patients underwent Nissen fundoplication and 25 patients underwent Toupet fundoplication. Of the 108 patients, 81 patients (75%) had at least 1 year post-operative symptom data. Twenty-one patients (26%) had dysphagia at follow-up and among them, 5 patients (6%) had grade 2 dysphagia. There were no patients with grade 3 dysphagia at follow-up. Nine patients (11%) required post-operative dilation for dysphagia. Patients who had high lower esophageal sphincter pressure (LESP) (> 45 mmHg) and high integrated relaxation pressure (IRP) (> 15 mmHg) were more likely to have post-operative dysphagia. On multivariate logistic regression analysis, high LESP and high IRP (odds ratio=6.3; 95% CI, 1.3-31.7; p=0.015) and pre-operative dysphagia (odds ratio=4.4; 95% CI, 1.3-14.3; p=0.025) were identified as predictors of post-operative dysphagia.

Conclusions: Non relaxing hypertensive LES and pre-operative dysphagia were associated with a significantly higher incidence of post-operative dysphagia.

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