DELAYED RECURRENCE OF REFLUX SYMPTOMS AFTER MAGNETIC SPHINCTER AUGMENTATION: CHARACTERIZING THE PATIENTS AND ROLE OF ENDOSCOPIC DILATION
Inanc Sarici*1, Shahin Ayazi1,2, Sven Eriksson1, Margaret Gardner1, Kirsten Newhams1,2, Ping Zheng1, Blair Jobe1,2
1Esophageal Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA
Introduction: Clinical experience has shown that a subset of patients with initial complete resolution of reflux symptoms after magnetic sphincter augmentation (MSA) return with delayed symptom recurrence, concerning for failure of MSA. However, these patients may have no objective evidence of reflux and respond to endoscopic dilation. This group of patients are not well studied. The aim of this study was to characterize patients who present with delayed recurrence of reflux symptoms after MSA and assess the impact of dilation on their outcome.
Methods: This was a retrospective review of 775 patients who underwent MSA between 2013 and 2021 at our institution. Patients with complete resolution of reflux symptoms who had late recurrence of their symptoms were selected. They underwent endoscopy with dilation, pH-monitoring and manometry, at the time of recurrence. Patients were divided into two groups based on whether their delayed recurrent symptoms resolved after dilation. Demographic, clinical and objective testing data were compared between groups, preoperatively, at the time of recurrence and yearly after dilation.
Results: There were 43 (5.5%) patients who were symptom free for at least 18 months after MSA but presented with delayed recurrent reflux symptoms at a mean (SD) of 33.2 (13.0) months. Of these patients, 28 (65.1%) had recurrent symptom resolution after dilation that was durable at a mean (SD) of 17.3 (7.7) months. These patients were younger [52.0 (38-59) vs. 59.8 (53-66), p=0.020], but sex (p=0.185) and BMI (p=0.593) were similar between groups.
Preoperatively, patients who failed to respond to dilation had more frequent severe esophagitis (LA C or D) (26.6% vs. 3.5%, p=0.042), hiatal hernia (93.3% vs. 60.7%, p=0.032) and lower median (IQR) distal contractile integral (DCI) [1155(809-1910) vs. 2236 (1418-3793), p=0.032].
At the time of recurrence, patients who failed to respond to dilation had more recurrent hiatal hernia (33.3% vs. 3.5%, p=0.014), esophagitis (60% vs. 7.1%, p=0.001) and abnormal DeMeester score (>14.7) (66.6% vs. 22.2%, p=0.007). The manometry of those who did respond to dilation showed higher LES resting pressure [35.6(25-42) vs. 22.1(19-28), p=0.037], integrated relaxation pressure (IRP) [14.7(11-24) vs. 11.3(10-13), p=0.048] and DCI [1921(1567-3502) vs. 1083(798-1245), p=0.008].
After dilation, freedom from PPI was significantly higher in the resolution group (82.1% vs. 13.3%, p<0.001). No patients who responded to dilation underwent device removal, compared to 40% of those who failed to respond (p=0.001).
Conclusion: Recurrent reflux symptoms following resolution for minimum of 18 months occur in 5.5% of patients. Those without anatomical failure or objective evidence of reflux can be effectively managed with dilation alone. Patients who fail to respond to dilation have a more severe reflux disease prior to implant.
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