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THE DIAGNOSTIC DILEMMA OF MANOMETRICALLY DETECTED NON-ACHALASIA ESOPHAGOGASTRIC JUNCTION OUTFLOW OBSTRUCTION (EJOO): IMPLICATIONS IN SURGICAL DECISION-MAKING
Yoshihiro Komatsu*, Philip Jackson, Ali H. Zaidi, Fahim Habib, Samantha Martin, Emily Lloyd, Albert A. Civitarese, Toshitaka Hoppo, Blair Jobe
Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
Background: In the era of high-resolution manometry (HRM), non-achalasia EJOO can be detected in patients with symptoms of GERD such as heartburn, regurgitation and dysphagia. The purpose of this study was to evaluate the presentation and outcomes of surgical intervention in patients with EJOO.
Methods: This is a retrospective review in patients with EJOO who underwent surgical intervention from May 2014 through November 2016. EJOO was defined as a relaxation pressure > upper limit of normal, ± elevated intrabolus pressure and intact peristalsis. Patients were stratified into two groups based on type of surgical intervention: antireflux surgery (ARS) and myotomy. Surgery type was selected based on presenting symptoms, endoscopic findings and pH testing. Demographics, presenting symptoms, and preoperative objective testing results were analyzed. Surgical outcomes were assessed using a Likert scale (1-5), where 1 and 5 represented no improvement and complete symptomatic resolution, respectively. Independent t-test and Chi-Square tests were used to compare groups.
Results: A total of 1832 patients underwent HRM, of which 161 (9%) were diagnosed with EJOO and 56 of these underwent surgery. ARS (fundoplication, n=23; magnetic sphincter augmentation, n=13) was performed in 36 patients and myotomy (POEM, n=14; Heller with fundoplication, n=6) in 20 patients. There was no difference in age and BMI between groups, and more women were in the ARS group (p=0.027). Although all symptom types were present in both groups, the primary presenting symptoms were heartburn in the ARS group (70% vs. 35%, p=0.008) and dysphagia in the myotomy group (33% vs. 85%, p<0.001). The secondary symptom was regurgitation in both groups (p=0.72). Preoperative PPI use was more common in the ARS group (p=0.030). Presence of hiatal hernia (p=0.041), esophagitis (p=0.010) and abnormal DeMeester score (DMS) (p=0.015), were higher in ARS patients. There was no difference in lower esophageal sphincter (LES) length between groups; however, LES resting pressure (p=0.008), relaxation pressure (p=0.009), and intrabolus pressure (p=0.021) were higher in the myotomy group. There was no difference in esophageal peristaltic pressure or distal contractile integral. Mean follow-up for ARS and myotomy groups were 3.66 and 3.11 months, respectively. Symptomatic improvement was observed equally in both ARS and myotomy groups (p=0.309), with mean postoperative scores of 4.31 and 4.06, respectively.
Conclusion: EJOO likely results from two distinct mechanisms, which include GERD induced chronic fibrosis and a variant of achalasia. Although the majority of these patients are referred with symptoms of GERD, almost 50% had a negative DMS. The surgical approach in these patients should be weighted on the primary presenting symptom and objective testing as the approaches are diametrically opposed.
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