IMPACT OF SIZING PROTOCOL ON LONG-TERM DYSPHAGIA AFTER MAGNETIC SPHINCTER AUGMENTATION
Shahin Ayazi*1,2, Ping Zheng1, Sven Eriksson1, Steven Tamesis1, Ali H. Zaidi1,2, Meghan Allen1, Ashten N. Omstead1, Blair Jobe1,2
1Allegheny Health Network, Pittsburgh, PA; 2Drexel University, Philadelphia, PA
Dysphagia is the most common complaint after magnetic sphincter augmentation (MSA). Studies show lower rates of dysphagia in patients with larger size devices (higher number of magnetic beads). To assist with the determination of the appropriate device size, a sizing tool is placed around the esophagus in the dissected space and tightened until the ring opens, which defines the pop-off point (POP), expressed as number of beads. Previously, many centers sized devices by increasing the POP by 2 beads. In an attempt to decrease the rate of dysphagia, these centers have recently changed their sizing protocol, increasing to 3 beads above the POP. There is limited data on the impact of this change on the rate of postoperative dysphagia. We designed the current study to evaluate the impact of this change in sizing protocol on the outcome of MSA.
This is a retrospective review of prospectively collected data of 522 patients who underwent MSA at our institution in a 7-year period (2013- 2020). We modified our sizing protocol beginning March 2018 to 3 beads above POP (POP+3) from 2 beads above (POP+2). The clinical and objective outcome at one year follow-up from surgery was compared between the two protocols. Dysphagia was defined as a postoperative score of ? 3 for the dysphagia-specific item in the GERD-HRQL.
There were 359 patients who had their device sized with the POP+2 protocol and 163 patients who had their device sized with the POP+3 protocol. Among 522 patients, dysphagia was reported by 80 (15.3%), and this rate was lower in patients with a large device (> 15 beads) compared to rest (<15 beads) (11.1% vs. 18.2%, p=0.028). There was a trend towards use of large devices (size >15) with the POP+3 protocol (46.9% vs. 39.3%, p=0.105).
In the POP+3 group the rate of dysphagia was similar to POP+2 (15.4% vs. 15.3, p=0.99). The groups were also similar in regard to post-op GERD-HRQL total score [4.0 (1.0- 12.0) vs. 5.0 (2.0- 12.0), p=0.0737], rate of satisfaction from surgery (82.9% vs. 86.5%, p=0.30) and rate of pH normalization (DeMeester score <14.7) (77.5% vs. 73.8%, p=0.48).
Although larger devices are associated with lower rates of dysphagia following MSA, changing the sizing protocol from POP+2 to POP+3 did not result in lower rates of dysphagia at our center. This finding highlights the complex nature of post-MSA dysphagia, which is the result of a multifaceted interplay between esophageal motility, device size, host response to implant, individual subjective perception of dysphagia, among other factors. Multicenter studies with large groups of patients are required to control for all contributing factors and to fully understand of this complex phenomenon.
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