IMPACT OF NISSEN FUNDOPLICATION ON NOVEL AND STANDARD HIGH RESOLUTION MANOMETRIC CHARACTERISTICS
Lubomyr Boris*1, Sven Eriksson1, Inanc Sarici1, Ping Zheng1, Sarah Scott1, Ashten N. Omstead1, Blair Jobe1,2, Shahin Ayazi1,2
1Esophageal Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA
Introduction:
Restoration of lower esophageal sphincter (LES) competency by antireflux surgery affects esophageal body and esophagogastric junction function. The advent of high-resolution manometry (HRM) has increased the fidelity and detail with which these effects can be evaluated. However, in standard HRM interpretation, most characteristics used in surgical practice were developed with conventional manometry. To best utilize the potential of HRM technology, novel manometric characteristics must be evaluated. The aim of this study was to assess the impact of Nissen fundoplication on novel and standard HRM characteristics.
Methods:
Pre and postoperative HRM files for patients who underwent primary Nissen fundoplication at our institution from 2013 to 2021 were reanalyzed by a single investigator. Standard HRM characteristics included LES characteristics, integral relaxation pressure (IRP), distal contractile integral (DCI), mean wave amplitude (MWA), and contractile front velocity (CFV). Novel HRM characteristics included upper esophageal sphincter (UES) resting and residual pressures, distal latency (DL), transition point length between skeletal and smooth muscle contraction and bolus clearance. DL was defined as time between swallow initiation and contractile deceleration point and late latency (LL) as time between swallow initiation and the intersection of the distal esophageal contraction and LES. The length and duration between the UES at swallow initiation and the beginning of the smooth muscle contraction was also evaluated.
Results:
The study population included 81 patients with a median (IQR) age of 60.8 (51-69). Manometry was repeated at a median (IQR) of 13.3 (11-28) months after surgery.
Nissen fundoplication increased mean (SD) LES total length [2.7 (0.8) to 3.1 (0.7), p<0.001], abdominal length [0.2 (0.6) to 1.4 (0.9), p<0.001], and resting pressure [21.4 (13.5) to 26.0 (12.7), p=0.009]. IRP increased from 8.2 (6.7) to 11.4 (6.4) (p=0.0001). DCI (p=0.084), percent intact (p=0.085), MWA (p=0.224), and CFV (p=0.085) were unchanged.
Among novel characteristics, fundoplication increased DL [7 (1.2) to 8.2 (5.9), p<0.0001], LL [9.8 (2.5) to 10.1 (2.2), p=0.023], transition point length [2.5 (2.2) to 3.1 (2.4), p=0.008], and esophageal body length [21.9 (3.7) to 23.5 (2.4), p<0.0001]. Bolus clearance decreased from 68% (36) to 59% (36) after surgery (p=0.042). UES resting (p=0.068) and residual (p=0.105) pressures and smooth muscle contraction length (p=0.348) and duration (0.067) were similar before and after surgery.
Conclusions:
Nissen fundoplication increases LES characteristics and IRP, but has minimal impact on standard esophageal body characteristics. However, novel high resolution manometry characteristics suggest that fundoplication increases the esophageal body length and duration of propagation of esophageal peristalsis.
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