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High Resolution Manometric Predictors of Post-Fundoplication Dysphagia
Benjamin J. Robinson, Maria a. Cassera, Angi Gill, Christy M. Dunst*
Minimally Invasive Surgery Division, The Oregon Clinic, Portland, OR
INTRODUCTION
Post-fundoplication dysphagia is a well-described side effect of antireflux surgery. Esophageal manometry is a standard part of the preoperative evaluation prior to antireflux surgery. However, controversy exists regarding the value of traditional manometry to predict post-operative dysphagia after fundoplication. Today, high-resolution manometry (HRM) has replaced traditional water perfused systems for the analysis of esophageal physiology. The aim of this study was to evaluate the utility of HRM in predicting post-operative dysphagia in patients with an otherwise functioning Nissen fundoplication.
METHODS
Patients who underwent a laparoscopic Nissen fundoplication at a single institution were identified through a prospectively collected database. Patients were asked to undergo routine post-operative testing 6-12 months after surgery. Patients who had normal post-operative 24-hour pH test scores were eligible for the study. Of these patients, those without available raw data from preoperative HRM were excluded. Traditional ineffective motility (IEM) was defined as mean distal esophageal contraction amplitude of <30mmHg or 30% or less peristaltic waves. Post-operative dysphagia was graded using a standard scoring system (0=never, 1=1-2 times a month, 2=1-2 times per week, 3=daily). A symptom score of 2-3 was used to define post-operative dysphagia. Regression and association analysis of pre-operative manometric risk-factors were performed to determine predictors of post-operative dysphagia. P-values <0.05 were considered significant.
RESULTS
95 patients (41 male; 54 female) were included in the analysis. Mean post-operative length of follow up was 14.9 months (range: 2-73). 70.2% patients had normal scores on all HRM parameters. Any dysphagia was reported by 50% of patients (17% grade-1, 23.4% grade-2, and 9.5% grade-3) Nineteen patients had traditional IEM. Of those with dysphagia, one also had traditional IEM. On univariate analysis only distal latency (DL) was found to be a significant predictor (p<0.001) of grade-3 but not grade-2 dysphagia. On multivariate analysis, no preoperative factors were found to be significant predictors of grade-3 dysphagia, but contraction front velocity predicted grade-2 dysphagia.
CONCLUSION
Persistent daily dysphagia occurs in ~10% of patients following an otherwise successful Nissen fundoplication. Advancements in manometric technology provide additional data points in the preoperative analysis of these patients. This analysis reveals that elevated integrated relaxation pressure (IRP) is a useful new metric to predict post-operative dysphagia in addition to traditional identification of weak distal esophageal contraction amplitudes. Pre-operative factors as predictors of post-fundoplication dysphagia | Value | P-Value | | Peristalsis <70% | 0.626 | | DECA <30 mmHg | <0.001 | | DCI <450 mmHg-s-cm | 0.202 | | CFV >9 cm/s | 0.156 | | DL <4.5s | 0.642 | | IRP >15 mmHg | <0.001 | | IBP >30 mmHg | 0.743 | | Pre-operative dysphagia >2 | 0.942 | | Pre-operative dysphagia >3 | 0.447 |
Abbreviations: DECA-Distal esophageal contraction amplitude; DCI-Distal contraction amplitude; CFV-Contractile front velocity; DL-Distal latency; IRP-Integrated relaxation pressure; IBP-intrabolus pressure.
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