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SURGICAL MANAGEMENT OF PATIENTS WITH ESOPHAGEAL OUTFLOW OBSTRUCTION AND REFLUX

Anee Sophia Jackson, MD, Brian E Louie, MD, Dale Shultz, Alexander Farivar, MD, Adam J Bograd, MD, Ralph W Aye, MD. Swedish Medical Center

INTRODUCTION: A small proportion of patients are found to have esophageal outflow obstruction (EOO) and hypertensive lower esophageal sphincter (HLES) on manometry prior to fundoplication for reflux. The optimal surgical strategy for these patients in unclear. There is concern of inducing further dysphagia with a fundoplication, and a question if myotomy is necessary to relieve the outflow obstruction. This study aims to describe the clinical outcomes of patients with EOO and/or HLES undergoing fundoplication for reflux. We hypothesize that patients with reflux and EOO have improvement in dysphagia symptoms after fundoplication.

METHODS: Retrospective review of patients with EOO and/or HLESP who underwent a fundoplication between 2004-16. Outcomes measured at one year follow up include GERD-HRQL, dysphagia score and reintervention for dysphagia. Comparisons were of the group, paired analysis and to a matched control group with a normal LES.

RESULTS: Forty-six patients were identified with a high residual LESP (18.8 mmHg) and/or HLESP (53.6 mmHg) and DeMeester score 37.5. There were 27 females with a mean age of 51 years and BMI 29.9.

Overall, at baseline, patients reported dysphagia score of 32.6 and GERD-HRQL=24.75. Nearly half (22/46) had symptomatic dysphagia. Post operatively, the dysphagia score improved to 35.5 and the GERD-HRQL score to 7.31. Only 2 patients required PPI therapy. Five patients required reintervention due to dysphagia with balloon dilation (n=5) and/or reoperation (n=1).

Eight patients had a myotomy with fundoplication. At baseline the LESP was 43.1 mmHg and rLESP 15.8 mmHg. Preoperative dysphagia score was 24.6 and HRQL was 32. Seven had symptomatic dysphagia pre-operatively. Post-operatively, all but one had improvement in dysphagia with one requiring balloon dilation then surgery for dysphagia.   

Paired analysis of 17 patients with preoperative and one-year postoperative quality of life surveys showed significant improvement in GERD-HRQL scores (p-value 0.0001 ) and no change in dysphagia scores, p-value 0.6334 (Table 1).  When compared to 16 matched patients without EOO or HLES, the quality of life was similar in terms of dysphagia and GERD (Table 1). No patients in the normal LES group required reintervention.

CONCLUSIONS: Following fundoplication, EOO/HLES patients had an overall improvement in GERD symptoms and no worsening of dysphagia.  One year outcomes are similar between EOO/HLES patients and those with normal LES pressure and relaxation, with no difference in reported post-operative dysphagia or quality of life. There was a higher rate of early reintervention due to dysphagia in EOO/HLES patients. 


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

Abstract ID: 87106

Program Number: S116

Presentation Session: Residents/Fellows Session

Presentation Type: ResFel

58

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