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Society for Surgery of the Alimentary Tract

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Hoover Wu*1,2, Mikhail Attaar1,2, Harry Wong1,2, Michelle Campbell1,2, Kristine Kuchta2, Stephen P. Haggerty2, Woody Denham2, John G. Linn2, Michael Ujiki2
1University of Chicago, Evanston, IL; 2NorthShore University HealthSystem, Evanston, IL

A short floppy fundoplication has been the surgical dogma to prevent dysphagia after laparoscopic fundoplication while adequately addressing gastroesophageal reflux disease. The literature on the ideal length of narrowing (LON) of the gastroesophageal junction after fundoplication is sparse. The functional luminal imaging probe (FLIP) can be used during anti-reflux surgery to produce a visual representation of the LON. We hypothesize that a longer LON provides adequate control of GERD, however worse dysphagia.

Methods and Procedures:
A retrospective review of a prospectively maintained quality database was performed. Patients with FLIP measurements during laparoscopic fundoplication between August 2018 and March 2020 were included. FLIP measurements at the gastroesophageal junction were recorded without pneumoperitoneum at 40 mL balloon fill after fundoplication. Patients were separated into two groups based on distensibility index (DI). Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life Questionnaire (GERD-HRQL), and Dysphagia Score were collected up to two years. Comparisons were made using Spearman correlation coefficients (r) and two-tailed Wilcoxon rank-sum tests, with statistical significance set at p<0.05.

Eighty-eight patients underwent laparoscopic fundoplication (31% Nissen, 69% Toupet) and had FLIP measurements. Mean LON in the total cohort was 2.7'0.8cm and mean DI was 3.5'1.3mmHg/mm2. In patients with DI ' 3.5 mm2/mmHg, a longer LON was associated with lower RSI and GERD-HRQL scores (r=-0.50 and -0.65 respectively, p<0.05), however no significant association with dysphagia score. In the DI ' 3.5 mm2/mmHg group, LON > 2.5 cm had a lower RSI (1.1'1.7 vs. 7.7'6.4, p=0.012) and GERD-HRQL (1.1'1.4 vs. 3.7'3.3, p=0.046) compared to the DI > 3.5 mm2/mmHg group with LON ' 2.5 cm. There was no difference in dysphagia score between the two groups (p=0.54).

Impedance planimetry provides objective real-time measurements and images during anti-reflux surgery, which allows surgeons to measure the length of narrowing after fundoplication. A lower DI and longer LON after fundoplication led to superior GERD control at one year without an increase in dysphagia.

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