Laparoscopic Fundoplication Is Effective Treatment for Patients with Gastroesophageal Reflux and Absent Esophageal Contractility

Steven Tran,Ronan Gray,Feruza Kholmurodova,Sarah K Thompson,Jennifer C Myers,Tim Bright,Tanya Irvine,David I Watson

doi:10.1007/s11605-021-05006-0

Abstract

BackgroundAnti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, particularly in individuals with an aperistaltic esophagus (absent esophageal contractility). This study determined the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility. MethodsA prospective database was used to identify all (40) patients with absent esophageal contractility who subsequently underwent fundoplication (36 anterior partial, 4 Nissen). Cases were propensity matched based on age, gender, and fundoplication type with another 708 patients who all had normal motility. Groups were assessed using prospective symptom assessment questionnaires to assess heartburn, dysphagia for solids and liquids, regurgitation, and satisfaction with surgery, and outcomes were compared. ResultsAcross follow-up to 10 years, no significant differences were found between the two groups for any of the assessed postoperative symptoms. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5- and 10-year follow-up. No differences in overall patient satisfaction were identified across the follow-up period. ConclusionLaparoscopic partial fundoplication in patients with absent esophageal contractility achieves acceptable symptom control without significantly worse dysphagia compared with patients with normal contractility. Patients with absent contractility should still be considered for surgery.

Highlights

Laparoscopic anti-reflux surgery is an established treatment option for the management of refractory gastroesophageal reflux disease (GERD)[1,2,3]
In an attempt to mitigate the risk of persistent dysphagia following fundoplication, the original Nissen fundoplication has been modified to various partial fundoplication options such as the Dor and Toupet fundoplications, aiming to reduce the likelihood of creating an over-competent lower esophageal sphincter[9, 10]
Studies exploring the role of fundoplication in those with absent esophageal contractility are generally limited by small numbers, a lack of longer-term outcomes, and a lack of matched controls

Summary

Introduction

Laparoscopic anti-reflux surgery is an established treatment option for the management of refractory gastroesophageal reflux disease (GERD)[1,2,3]. Many patients with absent esophageal contractility are not offered or referred for surgical management by clinicians due to concerns about an excessive risk of persistent dysphagia. The aim of this study was to determine the long-term outcomes after fundoplication in patients with absent esophageal contractility, compared to those with normal esophageal contractility. Anti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, in individuals with an aperistaltic esophagus (absent esophageal contractility). This study determined the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5- and 10-year follow-up. No differences in overall patient satisfaction were identified across the follow-up period

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