Brexton Turner1, Melissa Helm1, Emily Hetzel1, Jon C Gould2. 1. Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, HUB 6th Floor, Milwaukee, WI, 53226, USA. 2. Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, HUB 6th Floor, Milwaukee, WI, 53226, USA. jgould@mcw.edu.
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.
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.
Authors: Sudip K Ghosh; John E Pandolfino; Qing Zhang; Andrew Jarosz; Nimeesh Shah; Peter J Kahrilas Journal: Am J Physiol Gastrointest Liver Physiol Date: 2006-01-12 Impact factor: 4.052
Authors: Joris A Broeders; David J Roks; Usama Ahmed Ali; David I Watson; Robert J Baigrie; Zhanguo Cao; Jens Hartmann; Guy J Maddern Journal: Ann Surg Date: 2013-05 Impact factor: 12.969
Authors: Joris A Broeders; David J Roks; Usama Ahmed Ali; Werner A Draaisma; André J Smout; Eric J Hazebroek Journal: Ann Surg Date: 2011-07 Impact factor: 12.969
Authors: Monika A Kwiatek; Kahrilas Kahrilas; Nathaniel J Soper; William J Bulsiewicz; Barry P McMahon; Hans Gregersen; John E Pandolfino Journal: J Gastrointest Surg Date: 2010-02 Impact factor: 3.452
Authors: Ugoeze Nwokedi; Duc T Nguyen; Leonora M Meisenbach; Ray Chihara; Edward Y Chan; Edward A Graviss; Min P Kim Journal: Surg Endosc Date: 2020-07-14 Impact factor: 4.584