The role of preoperative high resolution manometry in predicting dysphagia after laparoscopic Nissen fundoplication
The role of preoperative high resolution manometry in predicting dysphagia after laparoscopic Nissen fundoplication
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DOI：
10.1007/s00464-017-5932-z
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发表时间：
2018-05-01
影响因子：
3.1
通讯作者：
Borrazzo, Edward
中科院分区：
文献类型：
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作者：
Kapadia, Sonam;Osler, Turner;Borrazzo, Edward
腹腔镜胃底折叠术是治疗难治性胃食管反流病（GERD）的一种公认的手术方法。高分辨率食管测压（HRM）在术前评估中的应用通常用于确定胃底折叠术的程度，以优化反流控制，同时最大限度地减少术后吞咽困难的不良后遗症。评估术前HRM在预测手术结局中的作用，特别是术后吞咽困难和生活质量的风险评估，在接受腹腔镜Nissen胃底折叠术治疗GERD的患者中，（< 4周门诊），短期（3个月门诊），和长期（34 +/- 10.4个月的电话）如下-回顾性分析了146名18岁以上的患者，他们从7月1日开始在佛蒙特大学医学中心接受腹腔镜Nissen胃底折叠术，2011年至2014年12月31日完成，其中52例术前HRM患者符合入选标准。排除标准包括病史：（a）命名的食管动力障碍或失代偿;（B）食管癌;（c）术中发现食管旁疝。基础综合松弛压（IRP）升高，即吞咽后10 s内4 s食管下括约肌（LES）最大松弛的平均值，与胃底折叠术后吞咽困难的严重程度显著相关（r = 0.572，p < 0.0001，灵敏度和NPV为100%）和较差的生活质量（r = 0.348，p = 0.018）。在短期（r = 0.403，p = 0.018）和长期随访（r = 0.415，p = 0.005）中，术前吞咽困难的存在与胃底折叠术后吞咽困难独立相关。此外，平均波幅（r=-0.397，p = 0.006）和远端收缩积分（DCI）（r =-0.294，p = 0.047）升高与Nissen术后吞咽困难显著负相关。其他术前HRM参数与手术结果之间无显著相关性。食管下括约肌（LES）松弛不足伴吞咽（IRP升高）可显著预测术后长期预后不良，包括吞咽困难和生活质量评分。需要进一步评估针对功能抵抗LES的部分与全部胃底折叠术的定制抗反流手术方法。
Laparoscopic fundoplication is an accepted surgical management of refractory gastro-esophageal reflux disease (GERD). The use of high resolution esophageal manometry (HRM) in preoperative evaluation is often applied to determine the degree of fundoplication to optimize reflux control while minimizing adverse sequela of postoperative dysphagia.Assess the role of preoperative HRM in predicting surgical outcomes, specifically risk assessment of postoperative dysphagia and quality of life, among patients receiving laparoscopic Nissen fundoplication for GERD with immediate postoperative (< 4 weeks clinic), short-term (3-month clinic), and long-term (34 +/- 10.4 months of telephone) follow-up.Retrospective analysis of 146 patients over the age of 18 who received laparoscopic Nissen fundoplication at University of Vermont Medical Center from July 1, 2011 through December 31, 2014 was completed, of which 52 patients with preoperative HRM met inclusion criteria. Exclusion criteria included history of: (a) named esophageal motility disorder or aperistalsis; (b) esophageal cancer; (c) paraesophageal hernia noted intraoperatively.Elevated basal integrated relaxation pressure (IRP), which is the mean of 4 s of maximal lower esophageal sphincter (LES) relaxation within 10 s of swallowing, was significantly correlated with worsened severity of post-fundoplication dysphagia (r = 0.572, p < 0.0001 with sensitivity and NPV of 100%) and poorer quality of life (r = 0.348, p = 0.018) at up to 3-years follow-up. The presence of preoperative dysphagia was independently related to post-fundoplication dysphagia at short-term (r = 0.403, p = 0.018) and long-term follow-up (r = 0.415, p = 0.005). Also, both elevated mean wave amplitude (r=-0.397, p = 0.006) and distal contractile integral (DCI) (r = - 0.294, p = 0.047) were significantly, inversely correlated to post-Nissen dysphagia. No significant association was demonstrated between other preoperative HRM parameters and surgical outcomes.Inadequacy of lower esophageal sphincter (LES) relaxation with swallowing as delineated by elevated IRP is significantly predictive of worse long-term postoperative outcomes including dysphagia and quality of life scores. Further assessment of tailoring anti-reflux surgical approach with partial vs. total fundoplication to functionally resistant LES is required.