The role of preoperative high resolution manometry in predicting dysphagia after laparoscopic Nissen fundoplication
Laparoscopic fundoplication is an accepted surgical management of refractory gastro-esophageal reflux disease (GERD). The use of high resolution esophageal manometry (HRM) in preoperative evaluation is often applied to determine the degree of fundoplication to optimize reflux control while minimizing adverse sequela of postoperative dysphagia.
Assess the role of preoperative HRM in predicting surgical outcomes, specifically risk assessment of postoperative dysphagia and quality of life, among patients receiving laparoscopic Nissen fundoplication for GERD with immediate postoperative (< 4 weeks clinic), short-term (3-month clinic), and long-term (34 ± 10.4 months of telephone) follow-up.
Retrospective analysis of 146 patients over the age of 18 who received laparoscopic Nissen fundoplication at University of Vermont Medical Center from July 1, 2011 through December 31, 2014 was completed, of which 52 patients with preoperative HRM met inclusion criteria. Exclusion criteria included history of: (a) named esophageal motility disorder or aperistalsis; (b) esophageal cancer; (c) paraesophageal hernia noted intraoperatively.
Elevated basal integrated relaxation pressure (IRP), which is the mean of 4 s of maximal lower esophageal sphincter (LES) relaxation within 10 s of swallowing, was significantly correlated with worsened severity of post-fundoplication dysphagia (r = 0.572, p < 0.0001 with sensitivity and NPV of 100%) and poorer quality of life (r = 0.348, p = 0.018) at up to 3-years follow-up. The presence of preoperative dysphagia was independently related to post-fundoplication dysphagia at short-term (r = 0.403, p = 0.018) and long-term follow-up (r = 0.415, p = 0.005). Also, both elevated mean wave amplitude (r=-0.397, p = 0.006) and distal contractile integral (DCI) (r = − 0.294, p = 0.047) were significantly, inversely correlated to post-Nissen dysphagia. No significant association was demonstrated between other preoperative HRM parameters and surgical outcomes.
Inadequacy of lower esophageal sphincter (LES) relaxation with swallowing as delineated by elevated IRP is significantly predictive of worse long-term postoperative outcomes including dysphagia and quality of life scores. Further assessment of tailoring anti-reflux surgical approach with partial vs. total fundoplication to functionally resistant LES is required.
KeywordsHigh resolution manometry Nissen Fundoplication Dysphagia
Compliance with ethical standards
Drs. Sonam Kapadia, MD, Edward Borrazzo, MD, Turner Osler, MD, Allen Lee, MD have no conflicts of interest or financial ties to disclose.
- 3.Broeders JAJL, Mauritz FA, Ali UA, Draaisma WA, Ruurda JP, Gooszen HG, Smout AJPM, Broeders IAMJ, Hazebroek EJ (2010) Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease. Br J Surg 97:1318–1330CrossRefPubMedGoogle Scholar
- 4.Koch OO, Kaindlstorfer A, Antoniou SA, Spaun G, Pointner R, Swanstrom LL (2013) Subjective and objective data on esophageal manometry and impedance pH monitoring 1 year after endoscopic full-thickness plication for the treatment of GERD by using multiple plication implants. Gastrointest Endosc 77:7–14CrossRefPubMedGoogle Scholar
- 8.Del Genio G, Rossetti G, Brusciano L, Limongelli P, Pizza F, Tolone S, Fei L, Maffettone V, Napolitano V, del Genio A (2007) Laparoscopic Nissen-Rossetti fundoplication with routine use of intraoperative endoscopy and manometry: technical aspects of a standardized technique. World J Surg 31:1099–1106PubMedGoogle Scholar
- 22.Clarke JO, Gyawali CP, Tatum RP. High resolution manometry. Ann N Y Acad Sci 2011;349–357Google Scholar
- 25.Wang YT, Tai LF, Yazaki E, Jafari J, Sweis R, Tucker E, Knowles K, Wright J, Ahmad S, Kasi M, Hamlett K, Fox MR, Sifrim D (2015) Investigation of dysphagia after antireflux surgery by high-resolution manometry: impact of multiple water swallows and a solid test meal on diagnosis, management and clinical outcome. Clin Gastroenterol Hepat 13:1575–1583CrossRefGoogle Scholar