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Luca Provenzano, Matteo Santangelo, Giovanni Capovilla, Arianna Vittori*, Loredana Nicoletti, Francesca Forattini, Giulia Nezi, Michele Valmasoni, Andrea Costantini, Mario Costantini, Renato Salvador
Universita degli Studi di Padova, Padova, Veneto, Italy

Background: Assessing patients following Laparoscopic Fundoplication (LF) can be challenging. The role of High-Resolution Manometry (HRM) performed after LF is still unclear and debated. We sought to determine the HRM parameters of a functioning fundoplication and evaluate whether HRM could discriminate it from a tight or a defective one.

Methods: Patients who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication for GERD between 2009-2022 were included. Symptoms were scored using a dedicated symptom score (SS). HRM and 24-h pH monitoring (pH) were performed before and 6 months after surgery, regardless of patients' symptoms; > 3cm hiatal hernias were excluded. LF failure was defined as GERD symptom recurrence (SS >8) and/or an abnormal 24h-pH. The study population was divided in 5 groups: LN and LT patients with normal 24h-pH (LN pH- and LT pH+, respectively), LN and LT patients with pathological 24h-pH (LN pH+ and LT pH+ groups, respectively) and patients having a postoperative dysphagia score with an intensity > 2 (Dysph group). LES parameters (resting pressure, IRP, total and abdominal length), and esophageal body function were reviewed by 2 experts (RS,GC). Differences in the postoperative HRM metrics between groups were evaluated, irrespective of preoperative ones.

Results: During the study period, 123 patients (M:F=84:39) having pre- and postoperative HRM were recruited (figure 1): 89 showed no objective sign of GERD recurrence after LN (LN pH-: 41 patients) or LT (LT pH-: 48 patients); 21 showed an abnormal postoperative 24h-pH after LN (LN pH+: 15 patients) and LT (LT pH+: 6 patients). Five patients (all had LN) reported postoperative dysphagia (Dysph). Eight patients with GERD symptoms despite a normal 24h-pH were excluded from further analysis. LES resting pressure and total and intra-abdominal lengths were significantly lower in the LN pH+ group compared to the LN pH-, as well as LES resting pressure and abdominal length in the LT pH+ group compared to the LT pH-. The percentage of ineffective swallows was significantly higher in the LT pH- compared to LN pH-. No other differences were detected in the esophageal body motility. Furthermore, LT pH- patients showed a significantly lower LES resting pressure and IRP compared to LN pH-. Conversely, IRP was significantly higher in Dysph compared to LN pH-. All data are showed in table 1.

Conclusion: This study provides the benchmark HRM values for an effective LF and confirms that the evaluation of the neo-sphincter with HRM improves the clinical assessment of symptoms recurrence and can discern patients with a well-functioning wrap from those showing GERD recurrence for an ineffective one. Moreover, IRP significantly correlated with the occurrence of postoperative dysphagia. Even if effective, LT was associated with significantly lower LES resting pressure and IRP than LN.

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