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Is that ‘floppy’ fundoplication tight enough?

  • 2019 SAGES Oral
  • Published:
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Abstract

Background

Laparoscopic fundoplication is the treatment of choice for medically refractory gastroesophageal reflux disease (GERD). Surgeons seek to create a competent valve at the gastroesophageal junction (GEJ) but are careful to construct a ‘floppy’ fundoplication that is not too tight to minimize side effects. The endoscopic functional luminal-imaging probe (EndoFLIP®) uses impedance planimetry to assess the GEJ intraoperatively. We sought to determine if EndoFLIP variables are associated with symptomatic outcomes following fundoplication.

Methods

We conducted a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication at a single institution between 2014 and 2018. All patients met standard indications for antireflux surgery. Minimum diameter (Dmin), cross-sectional area (CSA), intra-bag pressure, and distensibility index of the GEJ were obtained at 30 mL volumes. GERD Health Related Quality of Life (GERD-HRQL) surveys were administered pre- and postoperatively. Patients were excluded if they underwent fundoplication without EndoFLIP assessment or if they did not complete a postop GERD-HRQL survey. Receiver operating characteristic curves were used to determine if EndoFLIP measurements were correlated with symptomatic outcomes.

Results

Forty-three patients met inclusion criteria. The change in Dmin and CSA measures during fundoplication were associated with daily or more frequent heartburn at 6 or more months postop. A decrease in Dmin of 0.15 mm or less (AUC = 0.718, sensitivity: 71%, specificity: 69%) and a decrease in CSA of 1.5 mm2 or less (AUC = 0.728, sensitivity: 71%, specificity: 70%) were associated with severe heartburn.

Conclusions

GEJ opening dynamics attained by EndoFLIP appear to be associated with symptomatic outcomes. When the Dmin and CSA do not decrease by a defined threshold, heartburn is more likely to be severe at 6 or more months postoperatively. This suggests that the fundoplication may not be tight enough to prevent persistent or recurrent GERD.

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Authors and Affiliations

  1. Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, HUB 6th Floor, Milwaukee, WI, 53226, USA

    Brexton Turner, Melissa Helm, Emily Hetzel & Jon C. Gould

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  1. Brexton Turner
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  2. Melissa Helm
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  3. Emily Hetzel
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  4. Jon C. Gould
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Correspondence to Jon C. Gould.

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Disclosures

Dr. Gould is a consultant for Torax/Ethicon. Mr. Turner, Ms. Helm, and Ms. Hetzel have no conflicts of interest or financial ties to disclose.

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Turner, B., Helm, M., Hetzel, E. et al. Is that ‘floppy’ fundoplication tight enough?. Surg Endosc 34, 1823–1828 (2020). https://doi.org/10.1007/s00464-019-06947-z

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  • DOI: https://doi.org/10.1007/s00464-019-06947-z

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