Ineffective Esophageal Motility in Patients with GERD is no Contraindication for Nissen Fundoplication

A practical approach to ineffective esophageal motility

BACKGROUND AND PURPOSE

Ineffective esophageal motility (IEM) is the most frequently diagnosed esophageal motility abnormality and characterized by diminished esophageal peristaltic vigor and frequent weak, absent, and/or fragmented peristalsis on high-resolution esophageal manometry. Despite its commonplace occurrence, this condition can often provoke uncertainty for both patients and clinicians. Although the diagnostic criteria used to define this condition has generally become more stringent over time, it is unclear whether the updated criteria result in a more precise clinical diagnosis. While IEM is often implicated with symptoms of dysphagia and gastroesophageal reflux disease, the strength of these associations remains unclear. In this review, we share a practical approach to IEM highlighting its definition and evolution over time, commonly associated clinical symptoms, and important management and treatment considerations. We also share the significance of this condition in patients undergoing evaluation for anti-reflux surgery and consideration for lung transplantation.

Ineffective esophageal motility: The impact of change of criteria in Chicago Classification version 4.0 on predicting outcome after magnetic sphincter augmentation

BACKGROUND

The most recent update of the Chicago Classification (CCv4.0) attempts to provide a more clinically relevant definition for ineffective esophageal motility (IEM). The impact of this new definition on predicting outcome after antireflux surgery is unknown. The aim of this study was to compare utility of IEM diagnosis based on CCv4.0 to CCv3.0 in predicting surgical outcome after magnetic sphincter augmentation (MSA) and to assess any additional parameters that hold value in future definitions.

METHODS

Records of 336 patients who underwent MSA at our institution between 2013 and 2020 were reviewed. Preoperative manometry files were re-analyzed using both Chicago Classification version 3.0 (CCv3.0) and CCv4.0 definitions of IEM. The utility of each IEM definition in predicting surgical outcome was then compared. Individual manometric components and impedance data were also assessed.

KEY RESULTS

Immediate dysphagia was reported by 186 (55.4%) and persistent dysphagia by 42 (12.5%) patients. CCv3.0 IEM criteria were met by 37 (11%) and CCv4.0 IEM by 18 (5.4%) patients (p = 0.011). CCv3.0 and CCv4.0 IEM were equally poor predictors of immediate (AUC = 0.503 vs. 0.512, p = 0.7482) and persistent (AUC = 0.519 vs. 0.510, p = 0.7544) dysphagia. The predicted dysphagia probability of less than 70% bolus clearance (BC) was 17.4%, higher than CCv4.0 IEM at 16.7%. When BC was incorporated into CCv4.0 IEM criteria, the probability increased significantly to 30.0% (p = 0.0042).

CONCLUSIONS & INFERENCES

The CCv3.0 and CCv4.0 of IEM are poor predictors of dysphagia after MSA. Adding BC to the new definition improves its predictive utility and should be considered in future definitions.

Expanded Indication for Magnetic Sphincter Augmentation: Outcomes in Weakly Acidic Reflux Compared to Standard GERD Patients

BACKGROUND

Magnetic sphincter augmentation (MSA) is a modern surgical anti-reflux technique with proven efficacy and low postoperative morbidity in patients with acidic reflux. The aim of this retrospective review study was to evaluate the symptomatic outcome of MSA in patients with weakly acidic reflux.

METHODS

From a prospectively collected clinical database, comprising all 327 patients that underwent MSA at our institution, a total of 67 patients with preoperative weakly acidic reflux measured in the 24-h impedance-pH-metry were identified. Postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD Health-Related Quality-of-Life (GERD-HRQL), alimentary satisfaction (AS), and patients' overall satisfaction were evaluated within highly standardized follow-up appointments. Furthermore, outcome of these patients was compared to the postoperative outcome of a comparable group of patients with a preoperative acidic reflux.

RESULTS

At a median follow-up of 24 months, none of the patients with weakly acidic reflux presented with persistent dysphagia, or underwent endoscopic dilatation or reoperation. The postoperative GERD-HRQL score was significantly reduced (2 vs. 20; p = 0.001) and the median AS was 9/10. Preoperative daily heartburn, regurgitations, and respiratory complaints were improved in 95%, 95%, and 96% of patients, respectively. A total of 10% of the patients continued to use PPIs postoperatively. No significant difference was observed in terms of postoperative outcome or quality of life when comparing weakly acidic reflux patients with those diagnosed with preoperative acidic reflux.

CONCLUSION

Magnetic sphincter augmentation significantly improves GERD-related symptoms and quality of life in patients with weakly acidic reflux with very low postoperative morbidity.

Current Advancement on the Dynamic Mechanism of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common clinical disease associated with upper gastrointestinal motility disorders. Recently, with improvements in living standards and changes in lifestyle and dietary habits, the incidence of GERD has been increasing yearly. However, the mechanism of GERD has not been fully elucidated due to its complex pathogenesis, and this had led to unsatisfactory therapeutic outcomes. Currently, the occurrence and development of GERD involve multiple factors. Its pathogenesis is mainly thought to be related to factors, such as lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, crural diaphragmatic dysfunction, hiatus hernia, and impaired esophageal clearance. Therefore, explaining the pathogenesis of GERD more clearly and systematically, exploring potential and effective therapeutic targets, and choosing the best treatment methods have gradually become the focus of scholars' attention. Herein, we reviewed current advancements in the dynamic mechanism of GERD to better counsel patients on possible treatment options.

Partial Fundoplication is Effective Treatment for Female Patients with Gastroesophageal Reflux and Scleroderma: A Multicenter Comparative Cohort Study

BACKGROUND

Patients with scleroderma often suffer from dysphagia and gastroesophageal reflux disease (GERD). Partial fundoplication is a validated anti-reflux procedure for GERD but may worsen dysphagia in scleroderma patients. Its utility in these patients is unknown. Here, we evaluate the efficacy and acceptability of partial fundoplication for the treatment of medically refractory GERD in patients with scleroderma.

METHODS

Analysis of a prospectively maintained database of patients who underwent fundoplication across 14 hospitals between 1991 and 2019. Perioperative outcomes, reintervention rates, heartburn, dysphagia, and patient satisfaction were assessed at 3 months, 1- and 3-years post-surgery.

RESULTS

A total of 17 patients with scleroderma were propensity score matched to 526 non-scleroderma controls. All underwent a partial fundoplication. Perioperative outcomes including complication rate, length of stay, and need for reoperation were similar between the two groups. Compared to baseline, both groups reported significantly improved heartburn at 3 months, 1- and 3-years following partial fundoplication. Surgery was equally effective at controlling heartburn across all follow-up timepoints in patients with or without scleroderma. Dysphagia to solids was more common in patients with scleroderma than controls at 3-months post-surgery, but was not significantly different to controls at 1- and 3-year follow-up. Satisfaction scores were high and comparable between both groups across all postoperative timepoints, with 100% of patients with scleroderma reporting that their initial choice to undergo surgery was correct.

CONCLUSIONS

Partial fundoplication controls reflux and is associated with a transient period of dysphagia to solids in patients with scleroderma. This approach is safe, effective and acceptable for patients with scleroderma and medically refractory GERD.

Influence of Wrap Fixation Technique on the Results of Fundoplication

BACKGROUND

Different techniques of wrap fixation in laparoscopic Nissen fundoplication (LNF) have been proposed with of the aim to reduce the complications, but the optimal technique is yet to be determined. The aim of our prospective study was to evaluate several techniques of wrap fixation and determine whether the application of a combined approach to perform wrap fixation reduces the failure rate in short-term and long-term follow-up.

MATERIALS AND METHODS

One hundred two patients with sliding or paraesophageal hiatal hernia (type I or type II), who underwent antireflux surgery were randomized into 2 groups. In group I, LNF was supplemented with suturing the wrap to the diaphragmatic crura (35 patients) or to the body of stomach (16 patients). This was dependent on the strength of the crura (defined as weak or strong). The control group (51 patients) underwent LNF without wrap fixation. All patients were assessed using a validated symptom and quality of life (gastroesophageal reflux disease-Health Related Quality of Life) questionnaire, 24-hour impedance-pH monitoring, and barium swallow.

RESULTS

At the 48-month follow-up, the overall rate of complications was not significantly different between the 2 groups; however, there was a tendency toward a lower frequency of reoperations in the first group (P=0.059). Fixation of the fundoplication of wrap was noted to lead to significantly lower rates of postoperative dysphagia (P<0.05). These patients (group I) were also found to have significant improvement in gastroesophageal reflux disease-Health Related Quality of Life score (from 19.3±13.2 to 4.3±3.9 vs. from 18.7±11.9 to 9.3±7.7).

CONCLUSION

Fixation of the Nissen fundoplication wrap has been shown to have a positive impact on the reduction of postoperative dysphagia and leads to an improvement in disease-specific quality of life.

Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up

Background

Various technical modifications of Nissen fundoplication (NF) that aim to improve patients’ outcomes have been discussed. This study aims to evaluate the effect of division of the short gastric vessels (SGV) and the addition of a standardized fundophrenicopexia on the postoperative outcome after NF.

Methods

283 consecutive patients with GERD treated with NF were divided into four groups following consecutive time periods: with division of the SGV and without fundophrenicopexia (group A), with division of the SGV and with fundophrenicopexia (group B), without division of the SGV and with fundophrenicopexia (group C) and without division of the SGV and without fundophrenicopexia (group D). Postoperative contrast swallow, dysphagia scoring, GEDR-HRQL and proton pump inhibitor intake were evaluated. A comparative analysis of patients with division of the SGV and those without (161 A + B vs. 122 C + D), and patients with fundophrenicopexia and those without (78 A vs. 83 B and 49 C vs. 73 D) was performed.

Results

Fundophrenicopexia reduced postoperative dysphagia rates (0 group C vs. 5 group D, p = 0.021) in patients where the SGV were preserved and reoperation rates (1 group B vs. 7 group A, p = 0.017) in patients where the SGV were divided. There was no significant difference in the postoperative rates of heartburn relief, dysphagia, gas bloating syndrome, interventions, re-fundoplication and the GERD-HRQL score between groups A + B and C + D, respectively.

Conclusion

Standardized additional fundophrenicopexia in patients undergoing Nissen fundoplication significantly reduces postoperative dysphagia in patients without division of the SGV and reoperation rates in patients with division of the SGV. Division of the SGV has no influence on the postoperative outcome of NF.

[Alternative Surgical Anti-Reflux Procedures]

Patient satisfaction when treated with acid-suppressing medication for chronic GERD disease is less than 70%. Surgical standardisation, centralisation, improved awareness of patient selection and new surgical methods have stimulated interest in surgical reflux therapy in recent years. Magnetic sphincter augmentation (MSA) seems to be a safe alternative to laparoscopic fundoplication, with reported complication rates of 0.1% and reoperation rates of 3.4% and is also effective (GERD-HRQL improvement from 19.9 to 4.1, p = 0.001 as well PPI cessation and pH normalisation in 79 and 89% of patients, respectively). Electric sphincter augmentation shows promising short-term results in small patient cohorts (92% symptomatic improvement). However, randomised controlled studies comparing these new techniques to the "gold standard" of laparoscopic fundoplication are still missing.

Laparoscopic Fundoplication Is Effective Treatment for Patients with Gastroesophageal Reflux and Absent Esophageal Contractility

BACKGROUND

Anti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, particularly in individuals with an aperistaltic esophagus (absent esophageal contractility). This study determined the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility.

METHODS

A prospective database was used to identify all (40) patients with absent esophageal contractility who subsequently underwent fundoplication (36 anterior partial, 4 Nissen). Cases were propensity matched based on age, gender, and fundoplication type with another 708 patients who all had normal motility. Groups were assessed using prospective symptom assessment questionnaires to assess heartburn, dysphagia for solids and liquids, regurgitation, and satisfaction with surgery, and outcomes were compared.

RESULTS

Across follow-up to 10 years, no significant differences were found between the two groups for any of the assessed postoperative symptoms. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5- and 10-year follow-up. No differences in overall patient satisfaction were identified across the follow-up period.

CONCLUSION

Laparoscopic partial fundoplication in patients with absent esophageal contractility achieves acceptable symptom control without significantly worse dysphagia compared with patients with normal contractility. Patients with absent contractility should still be considered for surgery.

Patients with ineffective esophageal motility benefit from laparoscopic antireflux surgery

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.