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Patients with ineffective esophageal motility benefit from laparoscopic antireflux surgery

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Abstract

Background

Gastroesophageal reflux disease (GERD) is a common chronic disorder of the gastrointestinal tract, affecting more than 50% of Americans. The development of GERD may be associated with ineffective esophageal motility (IEM). The impact of esophageal motility on outcomes post laparoscopic antireflux surgery (LARS), including quality of life (QOL), remains to be defined. The purpose of this study is to analyze and compare QOL outcomes following LARS among patients with and without ineffective esophageal motility (IEM).

Methods

This is a single-institution, retrospective review of a prospectively maintained database of patients who underwent LARS, from January 2012 to July 2019, for treatment of GERD at our institution. Patients undergoing revisional surgery were excluded. Patients with normal peristalsis (non-IEM) were distinguished from those with IEM, defined using the Chicago classification, on manometric studies. Four validated QOL surveys were used to assess outcomes: Reflux Symptom Index (RSI), Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL), Laryngopharyngeal Reflux Health-Related QOL (LPR-HRQL), and Swallowing Disorders (SWAL) survey.

Results

203 patients with complete manometric data were identified (75.4% female) and divided into two groups, IEM (n = 44) and non-IEM (n = 159). IEM and Non-IEM groups were parallel in age (58.1 ± 15.3 vs. 62.2 ± 12 years, p = 0.062), body mass index (27.4 ± 4.1 vs. 28.2 ± 4.9 kg/m2, p = 0.288), distribution of comorbid disease, sex, and ASA scores. The groups differed in manometry findings and Johnson–DeMeester score (IEM: 38.6 vs. Non-IEM: 24.0, p = 0.023). Patients in both groups underwent similar rates of Nissen fundoplication (IEM: 84.1% vs. Non-IEM: 93.7%, p = 0.061) with greater improvements in dysphagia (IEM: 27.4% vs. 44.2%) in Non-IEM group but comparable benefit in reflux reduction (IEM: 80.6% vs. 72.4%) in both groups at follow-up. There were no differences in postoperative outcomes. Satisfaction rates with LARS were similar between groups (IEM: 80% vs. non-IEM: 77.9%, p > 0.05).

Conclusion

Patients with ineffective esophageal motility derive significant benefits in perioperative and QOL outcomes after LARS. Nevertheless, as anticipated, their baseline dysmotility may reduce the degree of improvement in dysphagia rates post-surgery compared to patients with normal motility. Furthermore, the presence of preoperative IEM should not be a contraindication for complete fundoplication. Key to optimal outcomes after LARS is careful patient selection based on objective perioperative data, including manometry evaluation, with the purpose of tailoring surgery to provide effective reflux control and improved esophageal clearance.

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References

  1. Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD (2010) Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. https://doi.org/10.1007/s00464-010-1267-8

    Article  PubMed  Google Scholar 

  2. Peery AF, Crockett SD, Barritt AS et al (2015) Burden of gastrointestinal, liver, and pancreatic diseases in the United States. Gastroenterology 149(7):1731–1741.e3. https://doi.org/10.1053/j.gastro.2015.08.045

    Article  PubMed  Google Scholar 

  3. Liu L, Li S, Zhu K et al (2019) Relationship between esophageal motility and severity of gastroesophageal reflux disease according to the Los Angeles classification. Medicine (Baltimore) 98(19):e15543. https://doi.org/10.1097/MD.0000000000015543

    Article  Google Scholar 

  4. Kahrilas PJ, Bredenoord AJ, Fox M et al (2015) The Chicago classification of esophageal motility disorders, v30. Neurogastroenterol Motil. https://doi.org/10.1111/nmo.12477

    Article  PubMed  PubMed Central  Google Scholar 

  5. Leite LP, Johnston BT, Barrett J, Castell JA, Castell DO (1997) Ineffective esophageal motility (IEM): the primary finding in patients with nonspecific esophageal motility disorder. Dig Dis Sci. https://doi.org/10.1023/A:1018802908358

    Article  PubMed  Google Scholar 

  6. Chugh P, Collazo T, Dworkin B, Jodorkovsky D (2019) Ineffective esophageal motility is associated with impaired bolus clearance but does not correlate with severity of dysphagia. Dig Dis Sci 64(3):811–814. https://doi.org/10.1007/s10620-018-5384-x

    Article  CAS  PubMed  Google Scholar 

  7. Wirsching A, Zhang Q, McCormick SE, Hubka M, Low DE (2018) Abnormal high-resolution manometry findings and outcomes after paraesophageal hernia repair. J Am Coll Surg 227(2):181–188.e2. https://doi.org/10.1016/j.jamcollsurg.2018.03.033

    Article  PubMed  Google Scholar 

  8. Fuchs HF, Gutschow CA, Brinkmann S et al (2014) Effect of laparoscopic antireflux surgery on esophageal motility. Dig Surg 31(4–5):354–358. https://doi.org/10.1159/000368662

    Article  PubMed  Google Scholar 

  9. Addo A, Broda A, Reza Zahiri H, Brooks IM, Park A (2019) Resolution of anemia and improved quality of life following laparoscopic hiatal hernia repair. Surg Endosc. https://doi.org/10.1007/s00464-019-07054-9

    Article  PubMed  Google Scholar 

  10. Park A, Weltz AS, Sanford Z, Addo A, Zahiri HR (2019) Laparoscopic antireflux surgery (LARS) is highly effective in the treatment of select patients with chronic cough. Surgery (US). https://doi.org/10.1016/j.surg.2019.01.036

    Article  PubMed Central  Google Scholar 

  11. Sanford Z, Jayaraman S, Weltz AS, Reza Zahiri H, Park A (2020) The role of body mass index in determining clinical and quality of life outcomes after laparoscopic anti-reflux surgery. Surgery Endosc. https://doi.org/10.1007/s00464-019-06811-0

    Article  Google Scholar 

  12. Lu R, Addo A, Broda A et al (2020) Update on the durability and performance of collis gastroplasty for chronic GERD and hiatal hernia repair at 4-year post-intervention. J Gastrointest Surg. https://doi.org/10.1007/s11605-019-04438-z

    Article  PubMed  PubMed Central  Google Scholar 

  13. Weltz AS, Zahiri HR, Sibia US, Wu N, Fantry GT, Park AE (2017) Patients are well served by Collis gastroplasty when indicated. Surgery (US). https://doi.org/10.1016/j.surg.2017.04.005

    Article  Google Scholar 

  14. Ravi N, Al-Sarraf N, Moran T et al (2005) Acid normalization and improved esophageal motility after Nissen fundoplication: equivalent outcomes in patients with normal and ineffective esophageal motility. Am J Surg. https://doi.org/10.1016/j.amjsurg.2005.05.040

    Article  PubMed  Google Scholar 

  15. Baigrie RJ, Watson DI, Myers JC, Jamieson GG (1997) Outcome of laparoscopic Nissen fundoplication in patients with disordered preoperative peristalsis. Gut. https://doi.org/10.1136/gut.40.3.381

    Article  PubMed  PubMed Central  Google Scholar 

  16. Novitsky YW, Wong J, Kercher KW, Litwin DEM, Swanstrom LL, Heniford BT (2007) Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication. Surg Endosc Other Interv Tech. https://doi.org/10.1007/s00464-006-9126-3

    Article  Google Scholar 

  17. Park AE, Hoogerboord CM, Sutton E (2012) Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia. J Gastrointest Surg. https://doi.org/10.1007/s11605-012-1888-4

    Article  PubMed  Google Scholar 

  18. Belafsky PC, Postma GN, Koufman JA (2002) Validity and reliability of the reflux symptom index (RSI). J Voice. https://doi.org/10.1016/S0892-1997(02)00097-8

    Article  PubMed  Google Scholar 

  19. Velanovich V (2007) The development of the GERD-HRQL symptom severity instrument. Dis Esophagus. https://doi.org/10.1111/j.1442-2050.2007.00658.x

    Article  PubMed  Google Scholar 

  20. Carrau RL, Khidr A, Gold KF et al (2005) Validation of a quality-of-life instrument for laryngopharyngeal reflux. Arch Otolaryngol. https://doi.org/10.1001/archotol.131.4.315

    Article  Google Scholar 

  21. McHorney CA, Robbins JA, Lomax K et al (2002) The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III. Documentation of reliability and validity. Dysphagia. https://doi.org/10.1007/s00455-001-0109-1

    Article  PubMed  Google Scholar 

  22. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. https://doi.org/10.1016/j.jbi.2008.08.010

    Article  PubMed  Google Scholar 

  23. Bakhos CT, Petrov RV, Parkman HP, Malik Z, Abbas AE (2019) Role and safety of fundoplication in esophageal disease and dysmotility syndromes. J Thorac Dis 11(4):S1610–S1617. https://doi.org/10.21037/jtd.2019.06.62

    Article  PubMed  PubMed Central  Google Scholar 

  24. Nikolic M, Schwameis K, Kristo I et al (2020) Ineffective esophageal motility in patients with GERD is no contraindication for Nissen fundoplication. World J Surg 44(1):186–193. https://doi.org/10.1007/s00268-019-05229-y

    Article  PubMed  Google Scholar 

  25. Freys SM, Fuchs KH, Heimbucher J, Thiede A (1997) Tailored augmentation of the lower esophageal sphincter in experimental antireflux operations. Surg Endosc. https://doi.org/10.1007/s004649900565

    Article  PubMed  Google Scholar 

  26. Thor KBA, Silander T (1989) A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg. https://doi.org/10.1097/00000658-198912000-00005

    Article  PubMed  PubMed Central  Google Scholar 

  27. Gyawali CP, Sifrim D, Carlson DA et al (2018) Ineffective esophageal motility: concepts, future directions, and conclusions from the Stanford 2018 symposium. Neurogastroenterol Motil 2019: https://doi.org/10.1111/nmo.13584

    Article  PubMed  Google Scholar 

  28. Smith CD, Devault KR, Buchanan M (2014) Introduction of mechanical sphincter augmentation for gastroesophageal reflux disease into practice: early clinical outcomes and keys to successful adoption. J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2013.12.034

    Article  PubMed  PubMed Central  Google Scholar 

  29. Asti E, Bonitta G, Lovece A, Lazzari V, Bonavina L (2016) Longitudinal comparison of quality of life in patients undergoing laparoscopic Toupet fundoplication versus magnetic sphincter augmentation: observational cohort study with propensity score analysis. Medicine (US). https://doi.org/10.1097/MD.0000000000004366

    Article  Google Scholar 

  30. Munitiz V, Ortiz A, Martinez De Haro LF, Molina J, Parrilla P (2004) Ineffective oesophageal motility does not affect the clinical outcome of open Nissen fundoplication. Br J Surg. https://doi.org/10.1002/bjs.4597

    Article  PubMed  Google Scholar 

  31. Simić AP, Skrobić OM, Gurski RR, Šljukić VM, Ivanović NR, Peško PM (2014) Can different subsets of ineffective esophageal motility influence the outcome of Nissen fundoplication? J Gastrointest Surg. https://doi.org/10.1007/s11605-014-2607-0

    Article  PubMed  Google Scholar 

  32. Booth MI, Stratford J, Jones L, Dehn TCB (2008) Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry. Br J Surg. https://doi.org/10.1002/bjs.6047

    Article  PubMed  Google Scholar 

  33. Mello MD, Shriver AR, Li Y, Patel A, Gyawali CP (2016) Ineffective esophageal motility phenotypes following fundoplication in gastroesophageal reflux disease. Neurogastroenterol Motil. https://doi.org/10.1111/nmo.12728

    Article  PubMed  PubMed Central  Google Scholar 

  34. Broeders JA, Sportel IG, Jamieson GG et al (2011) Impact of ineffective oesophageal motility and wrap type on dysphagia after laparoscopic fundoplication. Br J Surg 98(10):1414–1421. https://doi.org/10.1002/bjs.7573

    Article  CAS  PubMed  Google Scholar 

  35. Hajibandeh S, Hajibandeh S, Pugh M, Winters D, Hobbs N, Tarazi M, Panda N, Dalmia S, Mansour M, Malik S (2018) Impact of Toupet versus Nissen fundoplication on dysphagia in patients with gastroesophageal reflux disease and associated preoperative esophageal dysmotility: a systematic review and meta-analysis. Surg Innov. https://doi.org/10.1177/1553350618799549

    Article  PubMed  Google Scholar 

  36. Patti MG, Robinson T, Galvani C et al (2004) Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg. https://doi.org/10.1016/j.jamcollsurg.2004.01.029

    Article  PubMed  Google Scholar 

  37. Zornig C, Strate U, Fibbe C, Emmermann A, Layer P (2002) Nissen vs Toupet laparoscopic fundoplication: a prospective randomized study of 200 patients with and without preoperative esophageal motility disorders. Surg Endosc Other Interv Tech. https://doi.org/10.1007/s00464-001-9092-8

    Article  Google Scholar 

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Funding

No financial support was received for this study.

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Authors and Affiliations

  1. Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Belcher Pavilion, Suite 100, Annapolis, MA, 21401, USA

    Alex Addo, Philip George, H. Reza Zahiri & Adrian Park

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  1. Alex Addo
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All authors certify that they accept responsibility as an author and have contributed to the concept, data gathering, analysis, manuscript drafting, and give their final approval.

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Correspondence to Adrian Park.

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Dr. Park reports grants and personal fees from Stryker, outside the submitted work; Dr. Addo, George, and Zahiri have no conflict of interest or financial or relevant financial ties to disclose

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Addo, A., George, P., Zahiri, H.R. et al. Patients with ineffective esophageal motility benefit from laparoscopic antireflux surgery. Surg Endosc 35, 4459–4468 (2021). https://doi.org/10.1007/s00464-020-07951-4

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