Ineffective Esophageal Motility and Dysphagia after Nissen Fundoplication: The Impact of New Chicago Classification Version 4.0 on Ability to Predict Outcome

Abstract

INTRODUCTION: The recently introduced Chicago Classification version 4.0 (CCv4) uses more restrictive criteria for ineffective esophageal motility (IEM). This new definition incorporates the following components: ≥50% failed swallows, >70% fragmented swallows, and >70% weak swallows. The impact of this update on surgical outcomes is unclear. This study compares the utility of CCv3 and CCv4 in predicting dysphagia after Nissen fundoplication. METHODS: This is a review of 206 patients who underwent manometry before operation and completed preoperative and postoperative GERD-Health-Related Quality of Life (HRQL) questionnaires. Manometry tracings were reanalyzed to define IEM based on CCv3 and CCv4 criteria. Persistent dysphagia was defined as ≥3 on the dysphagia-specific item on the 1-year postoperative GERD-HRQL. The utility of CCv4 IEM in predicting dysphagia after Nissen fundoplication was compared with that of CCv3 IEM. RESULTS: At 1-year follow-up, dysphagia was reported by 18.4% of patients. Under CCv3, 41.3% of patients were found to have IEM in comparison with 35.4% under CCv4. IEM was a reliable marker of dysphagia using either classification (Table). Receiver operating characteristic (ROC) analysis showed no difference in overall predictability between 2 classifications (p = 0.686). The most common abnormal component of IEM in CCv4 was ≥50% failed swallows. The individual components had similar accuracy in predicting dysphagia: ≥50% failed swallows (75.2%), >70% fragmented swallows (82.0%), and >70% weak swallows (76.2%). CONCLUSION: The more restrictive diagnosis of IEM under CCv4 does not impact the ability to predict dysphagia after Nissen fundoplication. The minimal improvement in specificity comes at the modest cost of sensitivity. Table - Sensitivity Specificity Accuracy Area under ROC curve (95% CI) Chicago Classification 3.0 (CCv3.0) 60.5% 63.1% 62.6% 0.62 (0.53, 0.71) Chicago Classification 4.0 (CCv4.0) 52.6% 68.5% 65.3% 0.61