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Lubomyr Boris*1, Sven Eriksson1, Ping Zheng1, Inanc Sarici1, Sarah Scott1, Shahin Ayazi1,2, Blair Jobe1,2
1Esophageal Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA

Dysphagia is a feared and poorly understood complication after Nissen fundoplication. High resolution manometry (HRM) can provide valuable insight into the pathophysiology of postoperative dysphagia. However, HRM provides more physiologic information than the standard manometry characteristics. The development of novel manometry characteristics may provide greater insight into the pathophysiology of dysphagia. The aim of this study was to assess standard and novel HRM characteristics in patients with and without dysphagia after Nissen fundoplication.

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 lower esophageal sphincter (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. Smooth muscle initiation time and length were measured between the UES at swallow initiation and the beginning of the smooth muscle contraction. Patients completed the GERD-HRQL questionnaire pre- and postoperatively. Clinically significant dysphagia was defined as a score ≥ 4 on the dysphagia-specific GERD-HRQL item.

The final study population consisted of 94 patients with a median (IQR) age of 60.8 (51-69). At a median (IQR) follow-up of 12.4 (10-16) months, 65% had at least 50% improvement in GERD-HRQL scores, freedom from PPI was 80.2%, patient satisfaction was 74.4% and pH-normalization was 86.7%.
There were 5 (5.3%) with clinically significant dysphagia. Dysphagia was associated with higher postoperative GERD-HRQL scores [48.5 (46-56) vs. 7.0 (3-18) p<0.001] and dissatisfaction (75% vs. 23%, p=0.0498). PPI use (p=0.172) and pH normalization (p=1.000) were similar.
Patients with dysphagia had lower DCI [658 (418-967) vs. 1333 (762-2895) p=0.175] and more percent weak swallows [30.0 (10-40) vs. 0.0 (0-10), p=0.075]; however, these were not significant. Among novel characteristics, transition point length was significantly longer in patients with dysphagia [5.7 (5-6) vs. 2.6 (1-4), p=0.047]. Additionally, smooth muscle initiation time [4.7 (4.5-6) vs. 4.4 (4-5), p=0.101] and length [9.1 (9-10) vs. 6.9 (6-8), p=0.075] were longer, but not significant. No other HRM characteristics were significant.

Dysphagia after Nissen fundoplication is associated with poor esophageal body contractility. Novel manometric characteristics suggest this may be due to a longer transition point between skeletal and smooth muscle contraction.

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