Sonam Kapadia, MD1, Turner Osler, MD2, Allen Lee, MD3, Edward Borrazzo, MD2. 1Harbor-UCLA Medical Center, 2University of Vermont Medical Center, 3University of Michigan Health System
Background: Laparoscopic fundoplication is an accepted surgical management of refractory gastroesophageal reflux disease (GERD). The use of an esophagram and/or standard esophageal manometry in preoperative evaluation is often applied to determine the degree of fundoplication to optimize reflux control and minimize adverse sequela of postoperative dysphagia. Current high resolution esophageal manometry (HRM) provides much more information than previously available, and the interpretation of these results have questionable benefit in decision making for surgeons.
Objective: Assess the role of preoperative HRM in predicting surgical outcomes, specifically risk assessment of postoperative dysphagia and quality of life, among patients receiving laparoscopic Nissen fundoplication for GERD. Assessment time points include the first postoperative visit (about 2 weeks from surgery), second postoperative visit (3 months from surgery) , and 34 (±10.4) months postoperative median telephone follow-up.
Study Design: Retrospective analysis of 146 patients over the age of 18 who underwent a laparoscopic Nissen fundoplication at the University of Vermont Medical Center from July 1, 2011 through December 31, 2014 was completed, of which 52 patients with preoperative HRM met inclusion criteria. Exclusion criteria included a history of: a) ineffective esophageal motility disorder or aperistalsis; b) achalasia; c) scleroderma; d) esophageal cancer; e) paraesophageal hernia noted intraoperatively.
Results: Elevated basal integrated relaxation pressure (IRP), mean of four seconds of maximal LES relaxation within 10 seconds of swallowing, was significantly correlated with higher severity of post-fundoplication dysphagia (r=0.57, p<0.0001) and poorer quality of life (r=0.35, p=0.018) at up to 3-years follow-up. The presence of preoperative dysphagia was independently related to post-fundoplication dysphagia at 3 months (r=0.40, p=0.018) and 34±10.4 months (r=0.42, p=0.005). Also, both elevated mean wave amplitude (p=0.006) and distal contractile integral (p=0.047) were significantly, inversely correlated to post-Nissen dysphagia. No significant association was demonstrated between other preoperative HRM parameters and surgical outcomes.
Conclusions: Elevated IRP reflecting inadequacy of lower esophageal sphincter relaxation with swallowing is significantly predictive of worse long-term postoperative outcomes including dysphagia and quality of life scores. Further assessment requires tailoring the anti-reflux surgical approach using partial versus total fundoplication for patients with elevated IRP.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80674
Program Number: S028
Presentation Session: Foregut 1
Presentation Type: Podium