Minimally Invasive Fundopolication is Effective for Patients with Severe Esophageal Hypomotility
Michael Goldberg, Michael Smith, Jeanette Zhang, Cherie Erikmen, Larry Kaiser, Abbas Abbas, Temple University School of Medicine, Philadelphia, PA
OBJECTIVE: Patients with recalcitrant gastroesophageal reflux disease (GERD) and coexisting severe esophageal hypomotility (EH), including aperistalsis or hypoperistalsis, may be at increased risk of persistent dysphagia (PD) after antireflux surgery. This study describes the outcomes of minimally invasive fundoplication (MIF) in this group of patients.
METHODS: All patients who underwent MIF for GERD from January, 2003 to June, 2014 at our institution were retrospectively reviewed. Patients underwent pH testing, esophageal manometry, and symptom assessment before and after surgery. Hypomotility was defined in patients having manometrically weak peristalsis (mean distal amplitude of contraction <50mmHg) and/or frequent failed peristalsis. All manometric data were reviewed in a multidisciplinary esophageal conference to obtain concensus on the diagnosis of severe EH. These patients were then offered a MIF. PD was defined as dysphagia lasting more than 6 weeks after surgery. Chart review was performed including preoperative, operative details, and postoperative data.
RESULTS: Thirty four patients with GERD and EH underwent MIF laparoscopically in 88% (30) and robotically in 12% (4). By manometry, 38% (13) had scleroderma esophagus, and 62% (21) had ineffective peristalsis. Ten patients (29%) had systemic scleroderma. Fundoplications performed included Toupet (30), Dor (2), and Nissen (2). Average hospital stay was 2.1 days. All patients tolerated oral feeding at mean of 1.4 days. Thirty day morbidity was 9% (3) and included port site infection, blood transfusion for intraoperative bleeding, and ventilator-dependent respiratory failure. One patient required surgical revision at 4-months postoperatively. Mean follow up was 40 weeks and 50% (17) were asymptomatic while 50% (17) had reduced symptoms. Acid suppression medication was stopped or reduced in 51% (22). PD was noted in 5 patients (14.7%). Endoscopic dilation was done for 4 of these patients and esophageal botulinum toxin injection in 1. Dysphagia improved after these procedures in all 5 patients.
CONCLUSIONS: This study shows that MIF is both safe and effective in treating patients with severe GERD and concomitant EH. Although, the reported incidence of PD after fundoplication with normal esophageal motility ranges from 3% to 24%, in our study, the incidence was 16.6% and was well-managed by endoscopic means.