Omar Tageldin, MD, Muhammad Farhan Ashraf, MD, Rosa Bui, MD, Asra Batool, MD Albany Medical Center, Albany, NY
Introduction: Surgery for medically refractory gastroesophageal reflux disease (GERD) is a well-established treatment modality. The most used surgical techniques are total (Nissen) or partial (Toupet/dor) fundoplication (FP). Both techniques can result in undesired side effects including dysphagia. There are limited and conflicting data on the utility of the preoperative high resolution esophageal manometry (HRM) in tailoring the degree of FP. We aim to assess the role of preoperative HRM in patient selection, suggesting extent of the wrap and prediction of possible postoperative side effects.
Methods: After obtaining IRB approval, patient over 18 years of age who underwent HRM at our medical center from 10/01/2014 to 06/01/2020 were included in this study. 373 patients were identified in the EMR. Patients who underwent HRM for reasons other than preoperative FP were excluded from the study. The mean duration of follow-up after FP was 12.3 months.
Results: Our analysis included 115 patients. The mean age was 56.5 years and the female to male ratio 2.5:1. 72.2% had hiatal hernia (HH). 38.3% had dysmotility of which 9.6% had esophageal breaks greater than 30%, 16.5% had low mean distal contractile integral (DCI). 50.4% had lower esophageal sphincter (LES) length < 2.7 cm. 89.6% underwent Toupet FP based on our recommendation. 2.6% had mean DCI of more than 5000, 11.3% had high basal LES pressure and 13% had high integrated relaxation pressure (IRP). Although surgery was not recommended in these patients because of these findings, they still underwent partial FP either due to refractory symptoms or associated HH. Overall, 24.3% had persistent postoperative dysphagia. There was no statistically significant correlation in these patients with HRM findings of low DCI, basal LES pressure or peristaltic breaks except for high statistical significance with high DCI (P-value 0.049).
Discussion: HRM is an important tool in determining whether patients with refractory GERD are candidates for surgery or not. Some findings like high DCI, high IRP can recommend against surgery while findings like multiple breaks or low DCI can guide them towards choosing a partial wrap instead of a 360-degree wrap. We noted that despite some relative contraindications, patients still underwent partial FP without significant complications, however none of them underwent a total FP. We strongly recommend against performing FP in patients with high DCI as this has shown to be a significant predictor of postoperative dysphagia.
Omar Tageldin indicated no relevant financial relationships.
Muhammad Farhan Ashraf indicated no relevant financial relationships.
Rosa Bui indicated no relevant financial relationships.
Asra Batool indicated no relevant financial relationships.
Omar Tageldin, MD, Muhammad Farhan Ashraf, MD, Rosa Bui, MD, Asra Batool, MD. P2418 - Role of Preoperative High Resolution Esophageal Manometry in Guiding Fundoplication Procedure Technique and Postoperative Outcome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.