GASTROESOPHAGEAL REFLUX DISEASE (GERD) AFTER HELLER MYOTOMY WITH DOR FUNDOPLICATION: AN ASSESSMENT OF CONTRIBUTING FACTORS AND THE IMPACT ON OUTCOME
Sven Eriksson*1, Mohamad Rassoul Abu-Nuwar1, Inanc Sarici1, Ping Zheng1, Toshitaka Hoppo1,2, Blair Jobe1,2, Shahin Ayazi1,2
1Esophageal Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA
Introduction:
Heller myotomy with Dor fundoplication (HMD) is an effective palliative treatment for achalasia and its subtypes that incorporates an antireflux procedure to mitigate postoperative gastroesophageal reflux disease (GERD). However, there is paucity of data on the efficacy of reflux control after HMD or the impact of reflux control failure on outcome. The aim of this study was to characterize reflux control failure after HMD and its impact on outcome and to identify factors impacting the development of GERD.
Methods:
This is a retrospective review of patients who underwent HMD at our institution between 2013 and 2021. Favorable outcome was defined as a postoperative Eckardt score ≤ 3. Subjective GERD was defined as symptoms consistent with reflux. Objective GERD was based on a DeMeester score >14.7 or LA grade C/D esophagitis. Preoperative clinical and objective data and technical surgical elements were compared between those with and without GERD.
Results:
A total of 105 patients with a median (IQR) age of 61.0 (53-72) and BMI of 27.7 (32-31) underwent HMD. At a median (IQR) follow-up of 20.8 (12-36) months, 91.4% achieved favorable outcome. Subjective and objective GERD were found in 10.5% and 30.2% of patients, respectively. Of those with objective GERD, 52.6% had no reflux symptoms. Subjective GERD patients had lower rates of favorable outcome (72.7 vs. 93.6%, p=0.028), but outcome was similar in patients with objective GERD (p=0.211). Males were more likely to have objective GERD (50.0% vs. 19.5%, p=0.018), but subjective GERD was similar between sexes (p=0.455). Age and BMI had no impact on subjective or objective GERD (p>0.05). Length of esophageal myotomy had no impact on subjective or objective GERD (p=0.781 and p=0.620, respectively). LES resting pressure was lower in patients with objective GERD [20.9 (16-24) vs. 26.4 (18-32), p=0.028], but similar in those with subjective GERD (p=0.843). Patients with objective GERD were more likely to have a LES resting pressure < 45 mmHg (68.4 vs. 34.1%, p=0.018).
Conclusion:
Reflux control after Heller myotomy with Dor fundoplication failed in 30.2% of patients, and was frequently asymptomatic. Male patients and those with a non-hypertensive preoperative LES were more likely fail from a reflux control standpoint, and should be closely followed postoperatively. Achalasia palliation after HMD was highly effective, but was negatively impacted by reflux symptoms.
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