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TREATMENT OF ATYPICAL GASTROESOPHAGEAL REFLUX SYMPTOMS WITH MAGNETIC SPHINCTER AUGENTATION
Oliver C. Bellevue*1, Ralph W. Aye2, Philip Katz3, Alexander S. Farivar 2, Adam J. Bograd2, Brian E. Louie2
1General Surgery, Swedish Medical Center, Seattle, WA; 2Thoracic Surgery, Swedish Medical Center, Seattle, WA; 3Gastroenterology, Weill Cornell Medicine, New York, NY
Objectives: Magnetic sphincter augmentation (MSA) has been shown to effectively treat typical GERD symptoms (heartburn and regurgitation) and is an accepted alternative to fundoplication in these patients. However, the ability of MSA to control atypical symptoms has not been extensively studied. We sought to determine if MSA was also effective in treating atypical GERD symptoms.
Methods: We retrospectively reviewed patients undergoing MSA from three prospectively collected databases [Pivotal Trial (N=100), PAS Trial (N=200) and our institutional esophageal database (N=120)] from 2005-2016. Patients with atypical symptoms (cough, laryngitis, asthma, sore throat, hoarseness) were compared to those with only typical symptoms. Clinical, endoscopic, manometric, pH data, and intraoperative factors were analyzed.
Results: A total of 420 subjects were identified: 118 with typical symptoms alone, 302 with atypical symptoms (11 with atypical symptoms alone and 291 with both typical and atypical symptoms).
At baseline, patients with any atypical symptom were more likely to be older, female, less esophagitis and Barrett's compared to those with typical symptoms alone. HRQL scores were better compared to patients with only typical symptoms. (Table 1)
After MSA, patients with atypical symptoms had improved DeMeester scores from 38.0 to 17.2 (p=0.0001) and GERD HRQL score from 20.5 to 7.0 (p=0.0001). When compared to typical patients, there was no difference in DeMeester scores (19.5 v 17.2, p=0.40), GERD-HRQL scores (5.3 v 7.0, p=0.09), or dysphagia (42% v 49%, p=0.31). Patients with atypical symptoms reported more regurgitation (21 vs 35%, p=0.05). Postoperatively, 134/247 (54%) of patients with atypical symptoms had normalization of DeMeester scores compared to 58/83 (69%) of patients with typical symptoms (p=0.22).
In patients with only atypical symptoms (N=11), preoperative DeMeester scores (24.4) and GERD-HRQL scores (13.2) were significantly lower than patients with typical symptoms. After MSA, the DeMeester score improved to 12.6 (p=0.12) and GERD-HRQL to 4 (p=0.02). Only one patient with atypical symptoms experienced mild dysphagia postoperatively.
Conclusions: Magnetic sphincter augmentation improves atypical symptoms of GERD and provides objective evidence of acid control at similar rates to patients with purely typical GERD symptoms. Patients with pure atypical symptoms are uncommon in the current databases but appear to benefit from MSA.
Table 1. Baseline Characteristics.
| | Typical (n = 118) | Atypical (n = 302) | P-value | | Age, years (Mean +/- Stdev) | 47.7 +/- 14.0 | 50.7 +/- 12.7 | 0.045 | | Gender, % female (n, %) | 42, 36% | 154, 51% | 0.005 | | BMI (Mean +/- Stdev) | 27.7 +/- 3.8 | 27.1 +/- 4.1 | 0.244 | | Duration of PPI use, years (n, %) | 8.5 +/- 6.6 | 7.4 +/- 5.9 | 0.174 | | Pre-op Dysmotility (n, %) | 9, 8% | 23, 8% | 1.000 | | Pre-op Barrett's (n, %) | 17, 14% | 16, 5% | 0.004 | | Pre-op Esophagitis (n, %) | 41, 35% | 62, 21% | 0.004 | | Pre-op GERD-HRQL (Mean +/- Stdev) | 23.4 +/- 8.8 | 20.5 +/- 11.3 | 0.017 | | Pre-op DeMeester Score (Mean +/- Stdev) | 37.4 +/- 27.3 | 38.0 +/- 24.7 | 0.849 |
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