|
Back to 2017 Posters
PREOPERATIVE HIGH RESOLUTION MANOMETRY CRITERIA DOES NOT PREDICT DYSPHAGIA AFTER NISSEN FUNDOPLICATION
Steve Siegal*, Christy M. Dunst, Steven R. DeMeester, Ben Robinson, Lee L. Swanstrom
GMIS, The Oregon Clinic, Portland, OR
Background: Esophageal manometry, using water perfused systems that indicate failed peristalsis and weak contractile amplitudes are associated with a risk for post-fundoplication dysphagia, is widely used in the preoperative evaluation of patients undergoing antireflux surgery. Recently, high-resolution manometry (HRM) has become standard of care in esophageal physiologic testing. However, metrics derived from HRM have not been well correlated with the outcome of antireflux surgery. The aim of this study was to determine if distal contractile integral or other HRM variables reliably predict postoperative dysphagia after Nissen fundoplication.
Methods: The records of patients who underwent a laparoscopic Nissen fundoplication (LNF) from 2013-2015 were retrospectively reviewed. All patients had a preoperative HRM and patients without raw data from the manometry study were excluded. Per protocol at our center, a LNF was only offered to patients with confirmed GERD, a percent peristalsis (PP) >50% and distal esophageal contraction amplitude (DECA) > 25mmHg. HRM metrics such as distal contractile integral (DCI), contractile front velocity (CFV), and integrated relaxation pressure (IRP) were not included in preoperative patient selection. Dysphagia was graded using a standard system (0=never, 1=1-2 times a month, 2=1-2 times per week, 3=daily). A score of >2 defined dysphagia. Four groups were identified: those with new postoperative dysphagia (ND), never had dysphagia (NV), continued dysphagia (CD), and resolved dysphagia (RD).The Mann-Whitney test was used to identify significant differences in manometry criteria between groups.
Results: 94 patients were included (Table 1). Median follow up was 12 months. Pre-operative dysphagia was present in 23 patients overall (24.5%): it resolved in 65.2% and persisted in 34.8%. Among those with preoperative dysphagia, there were no significant differences in preoperative DCI or other manometry criteria between those whose dysphagia resolved and those whose dysphagia continued (Table 1). Thirty-two patients (34%) had postoperative dysphagia (75% new onset dysphagia, 25% continued dysphagia). Seventy-one patients (75.5%) did not have preoperative dysphagia. Of those, 33.8% developed new dysphagia and 66.2% never developed dysphagia. Neither DCI nor other manometry criteria significantly differed between those who developed new dysphagia or those with did not develop dysphagia (Table 1).
Conclusions: Pre-operative dysphagia typically resolves but approximately 25% of patients develop dysphagia after LNF. The risk of dysphagia after LNF is independent of preoperative dysphagia and esophageal manometric test results. Specifically, new HRM metrics (DCI, IRP and CFV) do not predict post-Nissen dysphagia in patients who are otherwise fundoplication candidates.
Table 1 - Manometry Values and Mann Whitney Test Between Dysphagia Groups
| | Preoperative Dysphagia | No Preoperative Dysphagia | | Manometry Criteria | Resolved Dysphagia (RD) N=15 | Continued Dysphagia (CD) N=8 | MW | New Dysphagia (ND) N=24 | Never Dysphagia (NV) N= 47 | MW | | DCI (median, range) | 1092 (309-2490) | 725.5 (99-2683) | p=0.27 | 881.5 (42-3613) | 1087 (94-5059) | p=0.88 | | DECA (median, range) | 80 (22-159) | 49.5 (29-124) | p=0.16 | 67 (21-127) | 70 (20-197) | p=0.80 | | PP (median, range) | 95 (20-100) | 90 (10-100) | p=0.64 | 90 (50-100) | 80 (40-100) | p=0.98 | | CFV (median, range) | 3.1 (2-30) | 3.8 (1-6) | p=0.94 | 4.4 (2-14) | 4 (2-19) | p=0.64 | | IRP (median, range) | 5.8 (-4.8-21) | 8.5 (-4-16) | p=0.92 | 6.5 (-8-25) | 6.1 (-6-17) | p=0.97 |
DECA - Distal Esophageal Contraction Amplitude (mmHg), PP - Percent Peristalsis (%), DCI - Distal Contractile Integral (mmHg*s*cm), CFV - Contraction Front Velocity (cm/s), IRP - Integrated Relaxation Pressure (mmHg), MW - Mann-Whitney Test
Back to 2017 Posters
|
