PREDICTORS OF PERSISTENT DYSPHAGIA AFTER MAGNETIC SPHINCTER AUGMENTATION
Shahin Ayazi*, Ali H. Zaidi, Ping Zheng, Kristy Chovanec, Yoshihiro Komatsu, Ashten N. Omstead, Madison Salvitti, Toshitaka Hoppo, Kirsten Newhams, Blair A. Jobe
Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
Introduction:
The magnetic sphincter augmentation was developed as a highly reproducible surgical option for the primary treatment of reflux. This procedure results in less severe side effects compared to Nissen fundoplication, but dysphagia remains the most common side effect reported by patients after MSA. This study aimed to identify the preoperative factors that predict persistent dysphagia after MSA.
Material and Methods:
This is a retrospective review of prospectively collected data of patients who underwent MSA between 2013 and 2018. Preoperative objective evaluation included upper endoscopy, esophagram, high-resolution impedance manometry (HRIM) and esophageal pH testing. Patients completed the GERD-HRQL questionnaire at baseline and at 6 and 12 months after surgery. At a minimum of 3 months following MSA, postoperative persistent dysphagia was defined as a postoperative score of ≥4 for the dysphagia-specific item within the GERD-HRQL. Univariate analysis was followed by logistic regression analysis. Results are reported as odds ratios (OR) with 95% confidence intervals (CI).
Results:
A total of 380 patients underwent MSA and were followed for a minimum of 6 months postoperatively. At a mean (SD) follow up of 11.5 (8.7) months, 59 (16%) of patients were experiencing persistent dysphagia, and 6 (1.6%) patients required device removal specifically for dysphagia.
Complete preoperative objective and clinical evaluation and baseline and postoperative GERD-HRQL data were available for 322 patients and were used in the univariate analysis and then logistic regression model. Independent predictors of persistent dysphagia included: 1) Absence of a large hernia [OR: 2.86 (95% CI: 1.08 - 7.57, p=0.035)]; 2) the presence of preoperative dysphagia [OR: 2.19 (95% CI: 1.05- 4.58, p=0.037)]; and 3) having less than 80% peristaltic contractions on HRIM [OR: 2.50 (95% CI: 1.09- 5.73, p=0.031)]. Graded cutoffs of distal contractile integral (DCI), mean wave amplitude, DeMeester score, sex and body mass index were evaluated within the model and did not predict postoperative dysphagia.
Conclusion:
In a large cohort of patients who underwent MSA, we report 16% rate of persistent postoperative dysphagia; and 1.6% of patients required device explantation for this symptom. Patients with normal anatomy, significant preoperative dysphagia, and less than 80% peristaltic contractions of the smooth muscle portion of the esophagus should be counseled that they have an increased risk for persistent postoperative dysphagia.
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