Clinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia

doi:10.1016/j.cgh.2018.10.020

Clinical Gastroenterology and Hepatology

Volume 17, Issue 10, September 2019, Pages 1982-1990

https://doi.org/10.1016/j.cgh.2018.10.020 Get rights and content

Background & Aims

Dysphagia is a consequence of antireflux surgery (ARS) for gastroesophageal reflux disease (GERD). We studied patient management and symptomatic outcomes.

Methods

We performed a retrospective study of 157 consecutive adult patients with GERD (mean age, 65.1 ± 1.0 y; 72% female) who underwent ARS at a tertiary care center from 2003 through 2014. We characterized postfundoplication dysphagia using a self-reported Likert scale, which ranged from a low score of 0 (no dysphagia) to a high score of 4 (severe daily dysphagia); scores of 2 or more indicated clinically significant dysphagia. Postfundoplication dysphagia was categorized as early (≤6 wk after ARS) or late (>6 wk after ARS), and Kaplan–Meier analyses were used to assess the time to development of clinically significant dysphagia. We performed univariate and multivariate analyses to assess management response and identify factors associated with dysphagia. The primary aim was to determine the prevalence and clinical course of postfundoplication dysphagia in patients with GERD treated with ARS.

Results

Of the 157 patients, 54.8% had early postfundoplication dysphagia (clinically significant in 20.4%); only 3.5% required endoscopic intervention. Over 2.1 ± 0.2 years of follow-up evaluation, 29 patients (18.5%) developed late postfundoplication dysphagia. Based on Kaplan–Meier analysis, the median time to clinically significant late postfundoplication dysphagia was 0.75 years (95% CI, 0.26–1.22). Of 13 patients (44.8%) who underwent endoscopic dilation, improvement was reported by 92.3%, with a mean decrease in dysphagia severity of 1.55 ± 0.3, based on the Likert scale. Prefundoplication dysphagia, early postfundoplication dysphagia, recurrent hiatal hernia, and lack of contraction reserve following multiple rapid swallows were univariate predictors of late postfundoplication dysphagia (P ≤ .04); lack of contraction reserve was associated independently with late postfundoplication dysphagia, based on multivariate logistic regression analysis (odds ratio, 3.73; 95% CI, 1.11–12.56).

Conclusions

Early and late postfundoplication dysphagia can be successfully managed conservatively or with endoscopic dilation, respectively. Lack of contraction reserve on multiple rapid swallows is associated independently with late postfundoplication dysphagia.

Section snippets

Patients

This study was a retrospective review of clinical data that were collected prospectively as part of a clinical evaluation for ARS. Consecutive adult patients ≥18 years old, undergoing initial ARS with hiatal hernia repair for management of well-characterized GERD, with or without structural esophagogastric junction disruption (hypotensive esophagogastric junction, axial or paraesophageal hiatus hernia), referred to a single surgeon (L.M.B.), at a tertiary care center between 2003 and 2014, were

Results

Within the study period, 188 patients underwent ARS and hiatal hernia repair, of which 31 patients had exclusion criteria (Figure 1). Of the 157 included patients (mean age, 65.1 ± 1.0 y; 72% female), the mean follow-up duration was 2.1 ± 0.2 years. Details regarding preoperative testing are described in Figure 1. Of postfundoplication symptoms at any time point, dysphagia to solids, liquids, or both was the most commonly reported by patients (101; 64.3%), followed by chest pain (76; 48.4%),

Discussion

In this article, we show that most patients with early postfundoplication dysphagia resolve with time and require no intervention, and those with clinically significant late postfundoplication dysphagia benefit from endoscopic dilation. Prefundoplication dysphagia, early postoperative dysphagia, and recurrent hiatus hernia were associated with clinically significant late postfundoplication dysphagia, but only lack of contraction reserve on provocative testing during HRM independently predicted

References (22)

C.P. Gyawali et al.
Management of gastroesophageal reflux disease
Gastroenterology
(2018)
B. Bello et al.
Gastroesophageal reflux disease and antireflux surgery-what is the proper preoperative work-up?
J Gastrointest Surg
(2013)
B.A. Jobe et al.
Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel
J Am Coll Surg
(2013)
N. Malhi-Chowla et al.
Dilation after fundoplication: timing, frequency, indications, and outcome
Gastrointest Endosc
(2002)
A. Patel et al.
Parameters on esophageal pH-impedance monitoring that predict outcomes of patients with gastroesophageal reflux disease
Clin Gastroenterol Hepatol
(2015)
P.K. Papasavas et al.
Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy
Surg Endosc
(2003)
S. Mehta et al.
Prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: seven-year follow-up
J Gastrointest Surg
(2006)
J.P. Galmiche et al.
Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial
JAMA
(2011)
A.E. Nicolau et al.
Quality of life after laparoscopic fundoplication for gastroesophageal reflux disease. Preliminary study
Chirurgia (Bucur)
(2013)
H. Yang et al.
Outcome following management of dysphagia after laparoscopic anti-reflux surgery
World J Surg
(2012)

I. Kellokumpu et al.

Quality of life following laparoscopic Nissen fundoplication: assessing short-term and long-term outcomes

World J Gastroenterol

(2013)

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Esophageal peristalsis
2024, Dysphagia: A Clinical Guide
The esophagus is a complex muscular tube; its main function is to transport a bolus from the pharynx to the stomach. This can be initiated by deglutition, termed primary peristalsis, or by local distension, such as during gastroesophageal reflux, termed secondary peristalsis. In this chapter, we review the normal physiology of esophageal primary and secondary peristalsis as well as disorders of peristalsis. Developed in the 1990s, high-resolution esophageal manometry (HRM) advanced motility testing by creating intuitive spatial and temporal representations of esophageal function. We will review the diagnostic and treatment approach of disorders of peristalsis by HRM as well as discuss other adjunctive esophageal testing, including the barium esophagram and the functional luminal imaging probe.
Esophageal Motility Patterns in Paraesophageal Hernia Patients Compared to Sliding Hiatal Hernia: Bigger Is Not Better
2023, Journal of Gastrointestinal Surgery
In patients with paraesophageal hernias (PEH), the course of the esophagus is often altered, which may affect esophageal motility. High-resolution manometry (HRM) is frequently used to evaluate esophageal motor function prior to PEH repair. This study was performed to characterize esophageal motility disorders in patients with PEH as compared to sliding hiatal hernia and to determine how these findings affect operative decision-making.
Patients referred for HRM to a single institution from 2015 to 2019 were included in a prospectively maintained database. HRM studies were analyzed for the appearance of any esophageal motility disorder using the Chicago classification. PEH patients had confirmation of their diagnosis at the time of surgery, and the type of fundoplication performed was recorded. They were case-matched based on sex, age, and BMI to patients with sliding hiatal hernia who were referred for HRM in the same period.
There were 306 patients diagnosed with a PEH who underwent repair. When compared to case-matched sliding hiatal hernia patients, PEH patients had higher rates of ineffective esophageal motility (IEM) (p<.001) and lower rates of absent peristalsis (p=.048). Of those with ineffective motility (n=70), 41 (59%) had a partial or no fundoplication performed during PEH repair.
PEH patients had higher rates of IEM compared to controls, possibly due to a chronically distorted esophageal lumen. Offering the appropriate operation hinges on understanding the involved anatomy and esophageal function of each individual. HRM is important to obtain preoperatively for optimizing patient and procedure selection in PEH repair.
Expanding the role of pneumatic dilation for nonachalasia patients: a comparative study
2023, Gastrointestinal Endoscopy
Treatment options for nonachalasia obstructive disorders of the esophagogastric junction (EGJ) are limited. The aim of this study was to assess the treatment efficacy of pneumatic dilation (PD) for the disorders of EGJ outflow obstruction (EGJOO) and postfundoplication EGJ obstruction (PF-EGJO) and to assess attitudes regarding training in PD.
This was a 2-part study. The main study was a prospective, single-center study comparing treatment outcomes after PD in patients with EGJOO and PF-EGJO, defined using manometry criteria, versus achalasia. Treatment success was defined as a post-PD Eckardt score (ES) of ≤2 at the longest duration of follow-up available. In a substudy, a 2-question survey was sent to 78 advanced endoscopy fellowship sites in the United States regarding training in PD.
Of the 58% of respondents to the advanced endoscopy program director survey, two-thirds reported no training in PD at their program. The primary rationale cited was lack of a clinical need for PD. Sixty-one patients (15 achalasia, 32 EGJOO, and 14 PF-EGJO) were included in the main study with outcomes available at a mean follow-up of 8.8 months. Overall, mean ES decreased from 6.30 to 2.89 (P < .0001), and a mean percentage of improvement in symptoms reported by patients was 55.3%. ES ≤2 was achieved by 33 of 61 patients (54.1%).
PD is an effective treatment for the nonachalasia obstructive disorders of the EGJ. There may be a current gap in training and technical expertise in PD.
Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics
2022, Gastroenterology
Citation Excerpt :
Symptom of dysphagia in most of these patients is generated due to inability of the esophageal propulsive force to distend the wrap for bolus transport into the stomach. Lack of contraction reserve on MRS has been independently associated with late postfundoplication dysphagia.30 Studies show that conventional endoscopic dilation of the wrap leads to symptom resolution in the majority of these patients with very few needing wrap takedown.26,30,142
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
Making Sense of Nonachalasia Esophageal Motor Disorders
2021, Gastroenterology Clinics of North America
Citation Excerpt :
During the swallows, peristalsis is temporarily inhibited, followed by a peristaltic wave with higher contraction vigor than single swallows, which indicates presence of contraction reserve.68 Contraction reserve on MRS has been shown to correlate with acid burden55 and may identify subsets of IEM that may not lead to postfundoplication dysphagia68,69 or IEM that improves over time.70 Thus, when IEM is identified in the context of reflux evaluation, or when assessing esophageal peristalsis before antireflux surgery, performing MRS during HRM may have a prognostic value.
Clinical usefulness of esophageal high resolution manometry and adjunctive tests: An update
2021, Digestive and Liver Disease
Citation Excerpt :
The ratio of MRS DCI to mean single swallow DCI is >1 when neural and muscular function is intact, termed contraction reserve [32]. The presence of contraction reserve in hypomotility disorders such as IEM can be associated with lower likelihood of post-fundoplication dysphagia [32,33], and lower esophageal acid exposure time (AET) [34]. At least three MRS maneuvers are required to demonstrate a consistent response [35].
High resolution manometry (HRM), developed from conventional manometry, is the gold standard for assessment of esophageal motor function worldwide. The Chicago Classification, now in its fourth iteration, is the modern standard for HRM categorization of esophageal motility disorders. The HRM protocol has expanded from the original 10 supine swallow standard, to include upright swallows, and provocative maneuvers such as multiple rapid swallows, rapid drink challenge and standardized test meal. Impedance has been incorporated into HRM for visualization of bolus clearance. Futhermore, barium radiography and functional lumen imaging probe complement HRM when evidence of esophagogastric junction obstruction is inconclusive. The biggest impact of HRM is in the improved diagnosis and subtyping of achalasia spectrum disorders, with implications on management. Spastic disorders and absent contractility are better characterized. Within the reflux spectrum, HRM provides definition of morphology and tone of the esophagogastric junction, and assesses integrity of esophageal body peristalsis, which have pathophysiologic implications for reflux and its clearance. HRM provides characterization of behavioral disorders such as supragastric belching and rumination syndrome, which can mimic reflux disease. Thus, HRM has revolutionized the evaluation of esophageal motor function, and has expanded the utility of esophageal manometry in clinical practice.

View all citing articles on Scopus

: Conflicts of interest The authors disclose no conflicts.

: Funding This study was funded in part through the Washington University Department of Medicine Mentors in Medicine.

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Original articleAlimentary tractClinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia

Background & Aims

Methods

Results

Conclusions

Section snippets

Patients

Results

Discussion

Gastroenterology

J Gastrointest Surg

J Am Coll Surg

Gastrointest Endosc

Clin Gastroenterol Hepatol

Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy

Surg Endosc

Prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: seven-year follow-up

J Gastrointest Surg

Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial

JAMA

Quality of life after laparoscopic fundoplication for gastroesophageal reflux disease. Preliminary study

Chirurgia (Bucur)

Outcome following management of dysphagia after laparoscopic anti-reflux surgery

World J Surg

Quality of life following laparoscopic Nissen fundoplication: assessing short-term and long-term outcomes

World J Gastroenterol

Original article
Alimentary tract
Clinical Characteristics and Outcomes of Patients With Postfundoplication Dysphagia