MAGNETIC SPHINCTER AUGMENTATION IN MANAGEMENT OF PATIENTS WITH LARYNGOPHARYNGEAL REFLUX (LPR) AND PREDICTORS OF FAVORABLE OUTCOME
Shahin Ayazi*, Kristy Chovanec, Ping Zheng, Ali H. Zaidi, Ashten N. Omstead, Adam Alleyne, Kirsten Newhams, Tameka Scott, Jonathan Levy, Toshitaka Hoppo, Blair A. Jobe
Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
Introduction:
Laryngopharyngeal reflux (LPR) is a challenging disease process to diagnose and treat and is poorly responsive to acid suppression therapy. Magnetic sphincter augmentation (MSA) has been applied with increasing frequency in the treatment of patients with reflux disease. The impact of this procedure in management of patients with LPR-dominate symptoms has not been examined. This study was designed to evaluate the impact of MSA in the management of LPR and to determine the variables associated with a favorable outcome.
Material and methods:
A total of 413 patients underwent MSA at our institution between 2013 and 2018. Patients with LPR-dominate symptoms who had a complete objective preoperative foregut evaluation were selected. All patients completed reflux symptom index (RSI) questionnaire at baseline and 6 and 12 months after surgery. RSI is a validated nine-item instrument for LPR with a score >13 being abnormal. Patients were considered to have a favorable outcome if they met the following criteria: resolution of the primary LPR symptom, freedom from antisecretory medication, and normalization or five-point improvement in RSI score. Preoperative clinical and objective data including high resolution manometry (HRM) and multichannel intraluminal impedance pH monitoring (MII) were analyzed to determine factors predicting a favorable outcome.
Results:
There were 87 patients [74% female, mean (SD) age: 56.5 (12.2)] who underwent MSA for LPR-dominate symptoms. At a mean follow up of 12 (8.6) months, RSI total score improved from 26.7 (9.6) to 11.2 (8.7), p <0.0001. Seventy-one (84%) patients had a favorable outcome by meeting all 3 study parameters. Patients with favorable outcome had a significantly higher preoperative RSI score compared to those with an unfavorable outcome [28.2 (8.9), vs 21 (10.6), p=0.02]. Patients with favorable outcome did not differ in demographic data (age, sex and BMI) or the individual components of their preoperative HRM study when compared to those with an unfavorable outcome.
In terms of preoperative MII results, patients with a favorable outcome had a similar total number of LPR events [1.4 (1.8), 1.3 (1.7), p=0.95] and total number of full column reflux events [14.4 (7.3), 13.1 (9.0), p= 0.61] compared to those with an unfavorable outcome. Patients with favorable outcome had a higher preoperative DeMeester score [38.5 (52.2) vs. 19.3 (14.4), p=0.0095]. Presence of a large hiatal hernia (>3 cm) was also higher in patients with a favorable outcome (24% vs. 0%, p=0.03).
Conclusion:
MSA is a highly effective treatment in selected patients with LPR-dominate symptoms. LPR patients with a high preoperative RSI score, more severe distal esophageal acid exposure, and a large hiatal hernia are more likely to have a favorable outcome with MSA compared to patients with less severe symptoms and normal preoperative anatomy.
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