Post-fundoplication Dysphagia Research Articles

A048 Managing Post-fundoplication Dysphagia: Role of Intraoperative LES Pressure Measurements with EndoFLIP

A048 Managing Post-fundoplication Dysphagia: Role of Intraoperative LES Pressure Measurements with EndoFLIP

Abnormal response after multiple rapid swallow provocation is not predictive of post-operative dysphagia following a tailored fundoplication approach.

The aim was to evaluate the clinical significance of multiple rapid swallows (MRS) during high-resolution manometry (HRM) prior to fundoplication. Despite pre-operative HRM, up to 38% of patients report post-fundoplication dysphagia. Suggestion that MRS improves prediction of dysphagia after fundoplication has not been investigated when using a tailored approach. We hypothesize response to MRS is predictive of dysphagia after tailored fundoplication. A retrospective cohort study was performed on patients undergoing HRM with MRS provocation 5/2019-7/2021 at a single institution. Patients who underwent subsequent index laparoscopic fundoplication, without peptic stricture or achalasia, were included. After performing standard 10-swallow HRM, MRS provocation was performed. Patient-reported dysphagia frequency scores were collected at initial consultation and post-operative follow-up. At least weekly symptoms were considered clinically significant. Normal MRS response was defined as adequate deglutitive inhibition and MRS contractile response. Fundoplications were tailored based on standard HRM values. HRM was performed in 1201 patients, 220 met inclusion criteria. Clinically significant pre-operative dysphagia was reported by 85 (38.6%). Patients undergoing partial fundoplication (n = 123, 55.9%) had lower mean distal contractile integer, distal esophageal contraction amplitude, and percent peristalsis (p < 0.005). Post-operatively, 120 (54.5%) were without dysphagia, 59 (26.8%) had improved dysphagia, 26 (11.8%) had unchanged dysphagia, and 15 (6.8%) reported new dysphagia. There was no statistical difference in early or late dysphagia outcome between tailored fundoplication groups (p = 0.69). On univariate and multivariate analysis, neither MRS response, nor standard HRM metrics were significantly associated with post-operative dysphagia. Younger age (OR 0.96, 95% CI 0.94-0.986, p = 0.042) and the presence of pre-operative dysphagia (OR 2.54, 95% CI 1.17-5.65, p = 0.015) were significant predictors of post-operative dysphagia. The risk of clinically significant dysphagia post-fundoplication is low when using a tailored approach based on standard HRM metrics. Additional data provided by MRS does not add to surgical decision-making using the investigated approach.

How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management.

Provocative tests have been advocated to address limitations of high-resolution manometry (HRM) with wet swallows. We describe the commonly used provocative manometric manoeuvres [rapid drink challenge (RDC), multiple rapid swallows (MRS), solid swallows and the solid test meal (STM)], compare their diagnostic yield and accuracy to wet swallows, and outline their role in directing clinical management. Provocative testing with RDC and STM identifies a proportion of achalasia cases missed by standard testing, and RDC can play a similar role to radiology in the evaluation of treatment response. In EGJOO, provocative testing with RDC and STM not only increase the diagnostic yield, but can also help differentiate between spurious cases and those representing true outflow obstruction likely to respond to achalasia-type therapies. MRS and STM can help determine the clinical relevance (or otherwise) of ineffective oesophageal motility, and in this setting, MRS may predict the likelihood of postfundoplication dysphagia. RDC and STM can help identify cases of postfundoplication dysphagia more likely to respond to dilatation. Provocative testing has been shown to increase diagnostic yield of HRM, clarify inconclusive diagnoses, allows corroboration of dysmotility with patient symptoms and helps direct clinical management.

Efficacy of Combined Hiatal Hernia Repair and Transoral Incisionless Fundoplication for Giant Paraoesophageal Hernias: Technique and Early Results.

Data is limited on hybrid transoral incisionless fundoplication (TIF) and hiatal hernia repair in giant paraoesophageal hernia (GPEH). We aimed to assess the safety, patient satisfaction, and symptom resolution following a hybrid paraoesophageal hernia (PEH) repair and TIF in patients with GPEH. All single-session hybrid TIF combined with minimally invasive PEH repair performed between February 2020 and June 2021 were evaluated. Procedures were performed in the operating room under general anesthesia with robotic or laparoscopic PEH repair followed by TIF. Twelve patients underwent combined surgical hiatal hernia repair and TIF. Primary presenting symptoms included heartburn (75.0%), dysphagia (41.7%), and chronic anemia from Cameron's ulcers (16.7%). The mean hernia defect size was 5.0 cm (range 3.0 to 6.0 cm). Hiatal hernia repairs were performed robotically in 7 patients and laparoscopically in 5 patients. The total mean operative time was 254 minutes (range: 180 to 390 min). One patient reported postoperative dysphagia requiring endoscopic dilation postdischarge with a resolution of symptoms. No gas-bloat symptoms were reported. All patients reported complete resolution of presenting symptoms at the time of follow-up. Postoperative mean follow-up for 4 patients at 6 months with upper endoscopy and pH testing showed an intact valve with no evidence of esophagitis or acid reflux. In our experience, hybrid hiatal hernia repair and TIF is a safe and effective therapeutic option for patients with GPEH. This hybrid procedure allows for more expeditious completion of the repair and results in lower rates of postfundoplication dysphagia and gas-bloat. Furthermore, this approach requires a less extensive surgical dissection on the greater curvature of the stomach, thereby minimizing the risk of vagal nerve injury and bleeding from the short gastric vessels.

Endoscopic management of gastrointestinal motility disorders.

Gastrointestinal motility disorders include several heterogeneous units affecting the esophagus, stomach, small or large intestine and the rectum. These are namely Zenkers diverticulum, esophageal achalasia, gastroesophageal reflux disease, gastroparesis, constipation, Ogilvies syndrome and post-fundoplication dysphagia. Given the progressive development of endoscopic techniques, patients with most of the above mentioned diseases can be offered a solution consisting of a mini-invasive endoscopic procedure which has already become a first-choice treatment for some of the disorders. This article summarizes the current role of endoscopy in the treatment of the most important gastrointestinal motility disorders.

Functional Luminal Imaging Probe in the Management of Pediatric Esophageal Disorders.

Functional luminal imaging probe (FLIP) measures pressure-geometry relationships of digestive luminal space. When used in esophageal disorders, it provides several luminal parameters that help better understand the pathophysiology. Data about the potential utility of FLIP in pediatrics are scarce and there is no standardized use in children. We aim to describe the use of FLIP in our center, its safety, feasibility, and clinical impact in esophageal disorders in children. Consecutive FLIP recordings performed at the Centre Hospitalier Universitaire-Sainte-Justine, Montréal, Canada between February 2018 and January 2021 were extracted. A chart review was conducted for demographics and medical history. Symptomatology after the procedure was evaluated with validated dysphagia scores. Nineteen patients were included (11 girls, median age 16 years, range 3.2-19.6) with achalasia (n = 5), post-Heller's myotomy dysphagia (n = 3), esophagogastric junction outflow obstruction (n = 3), congenital esophageal stenosis (n = 2); post-esophageal atresia repair stricture (n = 3), and post-fundoplication dysphagia (n = 3). There was no significant correlation between integrated relaxation pressure measured with high resolution manometry and distensibility index (DI). The use of FLIP made it possible to differentiate between dysphagia related to an esophageal obstruction (DI < 2.8 mm2/mmHg) and dysphagia without major motility disorder (DI > 2.8 mm2/mmHg) that guided the indication for dilation. FLIP led to a change in management in 47% of the patients. Forty-seven percent of the patients were symptom free at the time of the evaluation. FLIP provides key esophageal luminal values and therefore can play an important role in pediatric esophageal disorders management.

766 PROPHYLAXIS OF POST-FUNDOPLICATION SIDE EFFECTS AFTER LAPAROSCOPIC NISSEN EXTRA SOFT FUNDOPLICATION.

Abstract Laparoscopic Nissen Fundoplication (LNF) is well-established surgical treatment of GERD with best long-term postoperative outcomes in controlling reflux. Usually it is associated with a high risk of dysphagia, flatulence, inability to belch, bloating, which appear due to total over-tight wrap around esophagus. Partial fundoplication can avoid these effects, but unfortunately does not have the same long-term postoperative reflux control. So, new approach to prophylaxis of post-fundoplication side effects during LNF is needed. Methods Modified extra-soft LNF for GERD during 2016–2020 years were proposed in 75 patients. Prior to the fundoplication wrap formation the operation was performed according to the standard procedure. The proposed surgical techniques were: performing of an extra mobilization of the stomach (mandatory fundus and more ½ part of a large curvature) by crossing the gastro-splenic ligament completely and the gastro-colonic ligament partially and formation of a short extra-soft fundoplication wrap around the esophagus less 1.5 cm in the length with no more than 3 non-absorbable sutures with obligatory fixation to the esophagus. We examined twelve months follow-up. Results Along with the disappearance of GERD symptoms, no post-fundoplication dysphagia, flatulence, inability to belch and bloating were marked in any patient. Routine application of the above-described techniques allowed us to perform a modified LNF in all 75 patients by the extra mobilization of the stomach and formation of an extra-soft total fundoplication wrap with obligatory fixation to the esophagus without mandatory use of a thick (56–60 Fr) gastric fundoplication tube. Conclusion According to our study, in comparison with standard LNF, the proposed surgical techniques is effective in the prevention of post-fundoplication complications (dysphagia, flatulence, inability to belch, bloating) and support routine use of this modified Laparoscopic Nissen Extra Soft Fundoplication in treatment of GERD.

800 ASSOCIATION OF MULTIPLE RAPID SWALLOW PARAMETERS WITH SYMPTOMS IN PATIENTS WITH INEFFECTIVE AND NORMAL ESOPHAGEAL MOTILITY

Abstract Multiple rapid swallows (MRS) is a provocative test to assess inhibitory swallowing mechanisms and esophageal peristaltic reserve. MRS response has been purposed to predict post-fundoplication dysphagia and has been associated with increased acid exposure time. Recently it was added to the Chicago classification v 4.0 protocol as an adjunctive test. This study aimed to understand the association of MRS parameters with symptoms in patients within ineffective (IEM) or normal esophageal motility (NEM). Methods After IRB approval, a prospectively maintained esophageal motility database was retrospectively reviewed to identify patients with IEM and NEM who also had an MRS evaluation. Patients with previous gastroesophageal surgery, manometric hiatal hernia, or a diagnosed motility disorder (except IEM) were excluded. Patient-reported symptoms (0–4) (heartburn, regurgitation, dysphagia, and chest pain) were grouped by score: 0, 1–2, or 3–4. We compared the prevalence of normal or abnormal MRS and individual MRS parameters (distal contractile integral [DCI], integrated relaxation pressure, distal latency, adequate inhibition, and post-MRS DCI/mean single swallow DCI ratio) with patient-reported symptoms. Results From 2019–2020, a total of 531 patients (254 = IEM, 277 = NEM) met the inclusion criteria and formed the study cohort. The presence of normal or abnormal MRS results was not associated with any patient-reported symptom in either the NEM or IEM group. Furthermore, patient-reported symptoms were not associated with individual MRS parameters in either group. Conclusion In patients with IEM and NEM, adjunct assessment with MRS does not correlate with patient-reported symptoms. Further studies are needed to assess the role of MRS as an adjunctive test during routine manometry.

Quantification of fluoroscopic fundoplication anatomy: inter- and intraobserver reliability.

The etiology of postfundoplication dysphagia remains incompletely understood. Subtle changes of gastroesophageal junction (GEJ) anatomy may be contributory. Barium swallows have potential for standardization to evaluate postsurgical anatomical features. Using structured barium swallows, we aim to identify reproducible, objectively measured postfundoplication anatomical features that will permit future comparison between patients with/without dysphagia. At 6-12months of postfundoplication, 31 patients underwent structured barium swallow with video-fluoroscopy recording: standing anteroposterior; standing oblique (×2); prone oblique (×2); and prone oblique with continuous free drinking. A primary observer recorded 11 variables of GEJ anatomy for each view, repeated 3months later, forming two datasets to assess intraobserver consistency. Interobserver reliability was determined using a dataset each from the primary observer and two medical students (after training). Intraclass correlation coefficients (ICC) were based on two-way mixed-effects model (ICC agreement: 0.40-0.59 'fair'; 0.60-0.74 'good'; 0.75-1.00 'excellent'). Interobserver reliability was good-excellent for 47 of 66 measurements. Measures of maximal esophageal diameter cf. wrap opening diameter and posterior esophageal angle showed high interobserver reproducibility on all views (ICC range 0.84-0.91; 0.68-0.80, respectively). Interobserver agreement was good-excellent for 5/6 views when measuring anterior GEJ displacement and axis deviation (ICC range 0.56-0.79; 0.41-0.77, respectively). Measures of wrap length showed lower reproducibility. Prone oblique measurements showed highest reproducibility (good-excellent agreement in 19/22 measurements). Intraobserver consistency was excellent for 98% of measurements (ICC range 0.74-0.99). Objective measurements of postfundoplication GEJ anatomy using structured barium swallow are reproducible and may allow further interrogation of anatomical features contributing to postfundoplication dysphagia.

Esophagogastric junction outflow obstruction in the differential diagnosis of post-fundoplication dysphagia in children

Introduction and aimsPost-fundoplication dysphagia is resolved with no therapeutic intervention in the majority of cases but it can persist in 5.3% of children that undergo the procedure. Among the differential diagnoses, esophagogastric junction outflow obstruction (EGJOO) is a disorder that should be suspected if there is a persistence of dysphagia. The aim of our study was to describe the clinical characteristics, treatment, and follow-up in a case series of patients diagnosed with post-fundoplication EGJOO. Materials and methodsThe clinical records of patients diagnosed with EGJOO at a tertiary care hospital within the time frame of September 2015 to September 2019 were reviewed, with respect to manometry, etiology, treatment, and clinical course of the disease. ResultsOf the 213 high-resolution esophageal manometries performed, 4 patients met the criteria for post-fundoplication EGJOO. The primary symptom was dysphagia, presenting 15 days after the procedure. Esophageal dilations were carried out on all the patients but with no improvement. Symptoms related to the condition resolved spontaneously in three of the four patients. ConclusionThe management of children with post-fundoplication EGJOO continues to be a challenge. Even though more than half of the cases resolve with no intervention, optimum management of the motility disorder is still limited, given the scant experience with the condition in the pediatric population.

584 MULTIPLE OBSERVER DETERMINATION OF GASTRO-ESOPHAGEAL JUNCTION CHARACTERISTICS ON VIDEO-FLUOROSCOPY RELATING TO TROUBLESOME DYSPHAGIA POST-FUNDOPLICATION

Abstract Dysphagia is a common adverse effect of fundoplication and in some patients, there is no clear identifiable cause despite extensive investigation. Subtle anatomical features of anti-reflux surgery may relate to dysphagia. In this study multiple observers examine gastro-esophageal junction (GEJ) anatomy using objective measures of video-fluoroscopy swallow study (VFSS) to explore possible correlates with post-fundoplication dysphagia. Methods Thirty-one patients underwent structured VFSS 6–12 months after laparoscopic total (TotLF) or partial anterior (PAntLF) fundoplication recording: standing AP, 2x standing oblique (SOb), 2x prone oblique (POb), and prone oblique with continuous drinking (PObCont). Post-operative dysphagia was evaluated (Dakkak &amp; Bennett Score: range 0–45; troublesome ≥12). Three observers (Obs1–3) independently measured: GEJ displacement anteriorly; degree of axis deviation of esophagus &amp; GEJ (E-GEJ); posterior distal esophageal angle (PDEA); and GEJ opening diameter cf. maximal distal esophageal diameter (ME-GEJ). Correlations between measurements and dysphagia by operation type were assessed using linear regression analysis and linear mixed-effects models. Results Post-operatively, 5/18 TotLF and 4/13 PAntLF patients reported troublesome dysphagia. Three observers independently found: patients with troublesome dysphagia after TotLF had greater anterior displacement of the GEJ (SOb, range 0.61 cm–1.18 cm, Obs1 p = 0.04), and larger axis deviation of E-GEJ (POb, range 3.28°-13.07°, Obs2 p = 0.03) compared to patients with no/mild dysphagia. There was a trend for greater PDEA in patients with troublesome dysphagia after TotLF (POb, range 0.46°-2.12° and PObCont, range 3.37°-13.4°), but this trend did not reach statistical significance. Following PAntLF, all observers recorded a reduction in ME-GEJ for each unit of worsening dysphagia (PObCont, range 0.03 cm–0.04 cm, Obs1 p = 0.02, Obs2 p = 0.02). Conclusion Multiple observers concur that anterior GEJ displacement, the angle between the esophagus axis—GEJ axis, and posterior distal esophageal angulation are anatomical factors associated with troublesome dysphagia after total fundoplication. After partial anterior fundoplication, a small reduction in GEJ opening diameter relative to the distal esophagus related to worsening dysphagia. To reduce post-fundoplication dysphagia, attention to operative techniques affecting angulation and luminal diameter at the GEJ by fundoplication and hiatal repair is warranted.

583 THE INTER- AND INTRA-OBSERVER RELIABILITY OF A NOVEL VIDEO-FLUOROSCOPY PROTOCOL FOR GASTRO-ESOPHAGEAL JUNCTION ANATOMY POST-FUNDOPLICATION

Abstract Despite modifications in surgical technique, the occurrence of troublesome dysphagia after fundoplication remains difficult to predict. Objective measurements on video-fluoroscopy swallow study (VFSS) may hold the key to understanding post-fundoplication dysphagia. This study reports the inter- and intra-observer reliability of video-fluoroscopic anatomical measurements of the post-fundoplication gastro-esophageal junction (GEJ). Methods Thirty-one patients underwent structured VFSS 6–12 months after laparoscopic total or partial fundoplication. VFSS protocol included six views: standing AP, 2x standing oblique, 2x prone oblique (POb), and prone oblique with continuous drinking. The primary observer recorded two sets of 11 variables of GEJ anatomy (3 mo interval between set 1- set 2). Further datasets (one each) were obtained from two medical students trained in two 2-hour sessions. Inter-observer reliability was determined from datasets of three observers and intra-observer reliability from primary observer. Intraclass correlation coefficients (ICC) two-way mixed-effects model was used (ICC agreement: 0.40–0.59 “fair”; 0.60–0.74 “good”; 0.75–1.00 “excellent”). Results ICC for inter-observer reliability was good-excellent in 47/66 measurements. All measures of maximal esophageal diameter, maximal esophageal diameter cf. wrap opening diameter and posterior distal esophageal angulation were good-excellent (ICC range 0.74–0.78; 0.84–0.91; 0.68–0.80 respectively). Four parameters recorded 83% good-excellent ICC: wrap closing diameter, minimal wrap diameter, GEJ anterior displacement and degree of axis deviation (GEJ cf. esophagus) (ICC range 0.50–0.85; 0.58–0.93; 0.56–0.79; 0.41–0.77 respectively). Absolute and axial wrap length showed low reproducibility: “good” ICC in 25% of measurements. POb measurements were most reliable: good-excellent ICC 86% of times. Intra-observer reliability was excellent in 98% of measurements (ICC range 0.74–0.99). Conclusion Following a structured protocol, VFSS measurements of GEJ post-fundoplication anatomy are reliable between observers except for measures of absolute and axial wrap length. Measures from the POb view showed the greatest inter-observer reliability and may have higher clinical utility. Further studies using structured VFSS are warranted to determine the correlation between troublesome dysphagia and anatomical changes of the gastro-esophageal junction post-fundoplication.

Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia.

Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia. We prospectively collected data on PF patients referred to Esophageal Clinic over 18months. EGJO diagnosis was made by (a) endoscopist's description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8mm2/mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20mm, 30mm, or 35mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score. Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20mm balloon and 7 with ≥ 30mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7-82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1-88.4%, p = 0.0001). Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.

Obstrucción del tracto de salida de la unión esofagogástrica en el diagnóstico diferencial de disfagia posfunduplicatura en niños

Post-fundoplication dysphagia is resolved with no therapeutic intervention in the majority of cases but it can persist in 5.3% of children that undergo the procedure. Among the differential diagnoses, esophagogastric junction outflow obstruction (EGJOO) is a disorder that should be suspected if there is a persistence of dysphagia. The aim of our study was to describe the clinical characteristics, treatment, and follow-up in a case series of patients diagnosed with post-fundoplication EGJOO. The clinical records of patients diagnosed with EGJOO at a tertiary care hospital within the time frame of September 2015 to September 2019 were reviewed, with respect to manometry, etiology, treatment, and clinical course of the disease. Of the 213 high-resolution esophageal manometries performed, 4 patients met the criteria for post-fundoplication EGJOO. The primary symptom was dysphagia, presenting 15 days after the procedure. Esophageal dilations were carried out on all the patients but with no improvement. Symptoms related to the condition resolved spontaneously in three of the four patients. The management of children with post-fundoplication EGJOO continues to be a challenge. Even though more than half of the cases resolve with no intervention, optimum management of the motility disorder is still limited, given the scant experience with the condition in the pediatric population.

Long-term patient satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort: study protocol for a retrospective cohort study with development of a novel scoring system for patient selection

IntroductionLaparoscopic anti-reflux surgery is standard of care in surgical treatment of gastro-oesophageal reflux disease and is not without risks of adverse effects, including disruption of the fundoplication and postfundoplication dysphagia,...

Minor esophageal functional disorders: are they relevant?

High resolution esophageal manometry (HRM) has expanded understanding of esophageal motor function. The Chicago Classification scheme has allowed systematic categorization of the myriad of manometric parameters identified during HRM. Multichannel intraluminal impedance pH has enhanced ambulatory reflux monitoring through complete assessment of esophageal content transit. However, the clinical implications of identified minor esophageal functional disorders remain unclear. Esophagogastric junction outlet obstruction is defined by esophagogastric junction obstruction with preserved peristalsis and may be managed expectantly, or in a manner similar to achalasia. Hypercontractile esophagus has been associated with dysphagia and non-cardiac chest pain, but the clinical significance is unclear as a majority of patients will improve without specific therapy. Additionally, these findings may be confounded by chronic opiate use. Ineffective esophageal motility is characterized by diminished esophageal contraction amplitude, potentially causing dysphagia and GERD. However, this is commonly identified in asymptomatic volunteers and may represent a normal variant. The multiple rapid swallow sequence can assess esophageal contraction reserve, which may predict post fundoplication dysphagia. The post-swallow induced peristaltic wave can serve as a surrogate of gastric refluxate clearance, providing important prognostic value. However, the associated time burden and lack of alternative therapeutic options limit its clinical utility. Minor esophageal functional disorders provide new therapeutic targets for symptomatic patients. However, these findings have inconsistent associations with symptoms and poorly defined therapeutic options. Minor esophageal function disorders should not be interpreted in isolation, with management decisions accounting for clinical, endoscopic, and radiographic factors in addition.

453 Characterizing Esophageal Dysmotility in Patients With Post-Fundoplication Dysphagia

INTRODUCTION: Studies show that up to 90% of patients who undergo a fundoplication experience dysphagia post-operatively, and at least 10% of these patients' dysphagia will persist past 1 year. Little is known about possible causative etiologies. This project aims to manometrically characterize post-fundoplication dysphagia present in patients at least 1 year after surgery versus dysphagia controls with no prior history of gastric surgeries. METHODS: This is a single-center, retrospective chart review of patients who received a Nissen fundoplication for refractory GERD and were seen between January 2011 and February 2019 for post-fundoplication dysphagia lasting longer than 1 year before undergoing high resolution manometry (HRM). The 25 research subjects were matched to corresponding age, gender, and race-matched controls who were seen at the center for dysphagia during the same time period. The data collected includes demographics, symptoms, and findings from HRM, endoscopy, gastric emptying studies, pH impedance studies, and barium esophagrams. RESULTS: The mean lower esophageal sphincter respiratory basal pressure (LES RBP) was significantly lower in patients with fundoplication as compared to controls (P = 0.028). Patients with fundoplication had a significantly decreased distal contractile integral (DCI) as compared to controls (P = 0.0089). The ranges of DCI values between the two groups were notably different (subjects: 643-1500 mm Hg-cm-s; controls: 1654-3590 mm Hg-cm-s). Patients with post-fundoplication dysphagia were more likely to have a hypotensive LES (P = 0.096) and less likely to have a hypertensive LES (P = 0.023) compared to the dysphagia controls with no prior history of gastric surgery. Furthermore, they were more likely to have an esophageal dysmotility disorder—ineffective esophageal motility (43%), failed peristalsis (21%), fragmented peristalsis (7%), or diffuse esophageal spasm (29%) (P = 0.038). There were no significant differences between subjects and controls found in patient-reported symptoms, gastric emptying studies, pH impedance studies, barium esophagrams, and endoscopy reports. CONCLUSION: Many believe that esophageal hypomotility will improve in patients undergoing fundoplication for GERD. Our study demonstrates that post-fundoplication dysphagia is associated with higher rates of esophageal motor abnormalities, specifically esophageal hypomotility, when compared to dysphagia controls with no prior gastric surgical history.

Role of high resolution manometry in the diagnostic and therapeutic approach of post fundoplication dysphagia

Role of high resolution manometry in the diagnostic and therapeutic approach of post fundoplication dysphagia

Evaluation of Esophageal Contraction Reserve Using HRM in Symptomatic Esophageal Disease.

Esophageal high resolution manometry (HRM) is the gold standard for assessment of esophageal motor disorders, but motor responses to the standard 5 mL water swallow protocol may not provide precision in defining minor motor disorders. Provocative maneuvers, particularly multiple rapid swallows (MRS), have been used to assess deglutitive inhibition during the repetitive swallows, and the contractile response following the final swallow of the sequence. The augmentation of esophageal smooth muscle contraction following MRS is termed contraction reserve. This is determined as the ratio between esophageal body contraction vigor (distal contractile integral, DCI) following MRS to the mean DCI after single swallows, which is ≥1 in the presence of contraction reserve. Reliable assessment of contraction reserve requires the performance of 3 MRS maneuvers during HRM. Absence of contraction reserve is associated with a higher likelihood of late postfundoplication dysphagia and may correlate with higher esophageal reflux burden on ambulatory reflux monitoring. Esophageal motor responses to abdominal compression, functional lumen imaging probe (FLIP) balloon distension, and pharmacologic testing (using edrophonium and cisapride) may correlate with contraction reserve. Other provocative tests useful during HRM include rapid drink challenge, solid and viscous swallows, and standardized test meals, which are more useful in evaluation of esophageal outflow obstruction and dysphagia syndromes than in identification of contraction reserve. Provocative maneuvers have been recommended as part of routine HRM protocols, and while useful clinical information can be gleaned from these maneuvers, further research is necessary to determine the precise role of provocative testing in clinical esophagology.

Clinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia

Dysphagia is a consequence of antireflux surgery (ARS) for gastroesophageal reflux disease (GERD). We studied patient management and symptomatic outcomes. We performed a retrospective study of 157 consecutive adult patients with GERD (mean age, 65.1 ± 1.0 y; 72% female) who underwent ARS at a tertiary care center from 2003 through 2014. We characterized postfundoplication dysphagia using a self-reported Likert scale, which ranged from a low score of 0 (no dysphagia) to a high score of 4 (severe daily dysphagia); scores of 2 or more indicated clinically significant dysphagia. Postfundoplication dysphagia was categorized as early (≤6 wk after ARS) or late (>6 wk after ARS), and Kaplan-Meier analyses were used to assess the time to development of clinically significant dysphagia. We performed univariate and multivariate analyses to assess management response and identify factors associated with dysphagia. The primary aim was to determine the prevalence and clinical course of postfundoplication dysphagia in patients with GERD treated with ARS. Of the 157 patients, 54.8% had early postfundoplication dysphagia (clinically significant in 20.4%); only 3.5% required endoscopic intervention. Over 2.1 ± 0.2 years of follow-up evaluation, 29 patients (18.5%) developed late postfundoplication dysphagia. Based on Kaplan-Meier analysis, the median time to clinically significant late postfundoplication dysphagia was 0.75 years (95% CI, 0.26-1.22). Of 13 patients (44.8%) who underwent endoscopic dilation, improvement was reported by 92.3%, with a mean decrease in dysphagia severity of 1.55 ± 0.3, based on the Likert scale. Prefundoplication dysphagia, early postfundoplication dysphagia, recurrent hiatal hernia, and lack of contraction reserve following multiple rapid swallows were univariate predictors of late postfundoplication dysphagia (P ≤ .04); lack of contraction reserve was associated independently with late postfundoplication dysphagia, based on multivariate logistic regression analysis (odds ratio, 3.73; 95% CI, 1.11-12.56). Early and late postfundoplication dysphagia can be successfully managed conservatively or with endoscopic dilation, respectively. Lack of contraction reserve on multiple rapid swallows is associated independently with late postfundoplication dysphagia.