Abstracts
2000 Digestive Disease Week

# 2255 Severe Ineffective Esophageal Motility: Results of Antireflux Surgery.
Dennis Blom, Bowrey J. David, Tom R. Demeester, Jeffrey H. Peters, Cedric G. Bremner, Jeffrey A. Hagen, Steve R. Demeester, Reginald V. Lord, Michael G. Wood, Saj Wajed, Christopher Streets, Peter F. Crookes, Los Angeles, CA

INTRODUCTION: The ideal antireflux procedure for patients with gastroesophageal reflux disease (GERD) and impaired peristalsis is controversial. Concern about the creation of postoperative dysphagia has fueled the tendency to recommend partial fundoplications in such patients. The aim of this study was to assess the outcome of antireflux procedures in patients with GERD and profound ineffective esophageal motility (IEM), and identify factors predisposing to sustained postoperative dysphagia. METHODS: Thirty-four patients (M:F 25:9), median age 51.5 years (range 34 to 79) with severe IEM (amplitude < 30 mmHg in both distal stations on esophageal manometry) were studied a minimum of 6 months (median 7.5, range 6-43) after antireflux surgery. Dysphagia was measured using a standard scoring system: 0 = asymptomatic, 1 = mild not requiring diet modification, 2 = moderate requiring diet modification, 3 = severe requiring medical intervention. Variables evaluated included age, sex, esophageal and LES manometric characteristics, ambulatory pH, endoscopic findings and preoperative symptoms. Univariate and multivariate analyses were used to identify factors predictive for postoperative dysphagia. RESULTS: Nissen fundoplication was performed in 24%, Toupet in 26%, Belsey in 9%, and Collis-Belsey in 41%. Seventy six percent of patients had some disorganization of peristalsis as defined by the presence of simultaneous and/or interrupted contractions. Dysphagia was present in 41% before surgery, was relieved in 88% and persisted in 9% after surgery. Only 1 patient (3%) developed de novo dysphagia. Overall LES length was the only variable significantly associated with postoperative dysphagia (p<0.05) CONCLUSION: Dysphagia is common in patients with GERD and IEM. In most patients the symptom is relieved by surgery, even when a full 360o fundoplication is performed. Dysphagia postoperatively is very rare in patients who did not have preoperative dysphagia. Patients with IEM and a mechanically competent LES appear to be at slightly higher risk for postoperative dysphagia, suggesting that there may be a subgroup in which the motor defect is primary, rather than secondary to prolonged GERD.