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THE PADOVA CLASSIFICATION IN ACTION: AN INTERNATIONAL STUDY ON POST-FUNDOPLICATION OUTFLOW OBSTRUCTION (PFOO)
Francesca Forattini
*1, Khanh Hoang Nicholas Le
2, Luca Provenzano
1, Matteo Santangelo
1, Giovanni Capovilla
1, Arianna Vittori
1, Matteo Pittacolo
1, Loredana Nicoletti
1, Lucia Moletta
1, Michele Valmasoni
1, Rena Yadlapati
2, Renato Salvador
11Department of Surgical, Oncological and Gastroenterological Sciences,, Universita degli Studi di Padova, Padova, Veneto, Italy; 2University of California San Diego, San Diego, CA
BACKGROUND: Laparoscopic fundoplication (LF) is the surgical technique of choice for treating GERD, but it has been associated with various adverse effects, including dysphagia. One cause of dysphagia after LF includes post-fundoplication outflow obstruction (PFOO). According to the Padova Classification on postoperative High Resolution Manometry (HRM), PFOO is defined by a neo-lower esophageal sphincter (LES) with a higher basal pressure and/or integrated relaxation pressure (IRP), with or without signs of intrabolus pressure (IBP) during the swallow. The aim of this study is to assess clinical and HRM parameters of patients with manometric diagnosis of PFOO (PFOO) and secondarily to compare these parameters with those of asymptomatic patients with a functioning and effective LF (FELF), using new insights from the Padova Classification.
METHODS: This prospective study included patients evaluated at two referral centers for esophageal diseases. The PFOO group included patients with HRM diagnosis of PFOO (regardless of symptoms) after undergoing LF; the FELF group included asymptomatic patients (GerdQ score <8, no dysphagia) with manometric diagnosis of functioning and effective LF and with a normal postoperative 24h-pH study. We excluded patients with radiological and manometric signs of intrathoracic or slipped fundoplication. Presence of postoperative dysphagia was clinically assessed. LES parameters (basal pressure, IRP, total and abdominal length), IBP and esophageal body function were reviewed by an expert (RS). Differences in the postoperative HRM metrics between groups were statistically evaluated, irrespective of preoperative ones.
RESULTS: The study included 106 patients: 62 in the PFOO group and 44 in the FELF group (Figure 1). Patients’ demographic and clinical parameters are summarized in Table 1. The PFOO group had a median LES basal pressure of 31.2 mmHg (IQR 25.7-41.9 mmHg) and a median IRP of 18.3 mmHg (IQR 16.5-21.4 mmHg). Compared to the FELF group, the PFOO group showed significantly higher LES basal pressure (p<0.01), IRP values (p<0.01), LES total and abdominal lengths (p=0.01). Additionally, elevated IBP and esophageal motility disorders were also more frequent in PFOO patients (p<0.01 and p=0.01, respectively). Overall, in the PFOO group 89% of patients (55/62) had dysphagia and 45% (28/62) of them required re-treatment (pneumatic dilations, redo surgery or both). Among re-treated patients, the PFOO was attributed to a tight crura (8/28, 29%) or a tight wrap (12/28, 43%).
CONCLUSIONS: This is the first study evaluating the HRM parameters of patients with PFOO after LF, following the new Padova Classification. This study confirms the ability of HRM to discriminate an obstructive fundoplication from a functional one, and therefore, the diagnostic role of the Padova Classification to assess post-fundoplication dysphagia.
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