Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility
Gastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients.
A single-institution prospective database was reviewed (2007–2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05.
Fifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0 ± 18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1–7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia.
A tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.
KeywordsEsophageal dysmotility GERD Anti-reflux surgery Laparoscopic partial fundoplication
The contribution of each author, as defined by the ICMJE guidelines, is as follows: PRA: data acquisition, analysis, and interpretation; drafting and revision; final approval; accuracy and integrity; DH: data acquisition, analysis, and interpretation; drafting; final approval; accuracy and integrity; ML: data acquisition, analysis, and interpretation; revision; final approval; accuracy and integrity; AP: data acquisition, analysis, and interpretation; drafting; final approval; accuracy and integrity; AW: data acquisition, analysis, and interpretation; drafting; final approval; accuracy and integrity; DO: design of work, data acquisition, analysis, and interpretation; revision; final approval; accuracy and integrity.
Funding for this study was provided by the Center for Advanced Surgical Technology at the University of Nebraska Medical Center.
- 13.Rana G, Armijo PR, Krause C, Oleynikov D. Paraesophegal hernia. In: Oleynikov D, Fisichella MP, eds. A mastery approach to complex esophageal diseases. Berlin: Springer; 2018, pp 89–101.Google Scholar
- 31.Du X, Hu Z, Yan C, Zhang C, Wang Z, Wu J. A meta-analysis of long follow-up outcomes of laparoscopic nissen (total) versus toupet (270 degrees ) fundoplication for gastro-esophageal reflux disease based on randomized controlled trials in adults. BMC Gastroenterol. 2016;16(1):88-016-0502-8.CrossRefGoogle Scholar