Division of General Surgery, Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, HUB 6th Floor, Milwaukee, WI, 53226, USA.
Surg Endosc. 2020 Apr;34(4):1823-1828. doi: 10.1007/s00464-019-06947-z. Epub 2019 Jul 8.
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.
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.
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 mm or less (AUC = 0.728, sensitivity: 71%, specificity: 70%) were associated with severe heartburn.
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.
腹腔镜胃底折叠术是治疗药物难治性胃食管反流病（GERD）的首选方法。外科医生试图在胃食管交界处（GEJ）建立一个有效的瓣膜，但要小心构建一个“松弛”的胃底折叠术，不要太紧以最小化副作用。内镜功能腔内成像探头（EndoFLIP®）使用阻抗平面测量术在术中评估 GEJ。我们试图确定 EndoFLIP 变量是否与胃底折叠术后的症状结果相关。
我们对 2014 年至 2018 年期间在一家机构接受初次腹腔镜胃底折叠术的患者进行了前瞻性回顾性研究。所有患者均符合抗反流手术的标准适应证。在 30ml 容量下获得 GEJ 的最小直径（Dmin）、横截面积（CSA）、囊内压力和可扩张指数。在术前和术后进行胃食管反流病健康相关生活质量（GERD-HRQL）调查。如果患者未接受 EndoFLIP 评估或未完成术后 GERD-HRQL 调查，则排除在研究之外。使用受试者工作特征曲线来确定 EndoFLIP 测量值是否与症状结果相关。
43 名患者符合纳入标准。胃底折叠术期间 Dmin 和 CSA 测量值的变化与术后 6 个月或更长时间每天或更频繁出现烧心有关。Dmin 减少 0.15mm 或更少（AUC=0.718，灵敏度：71%，特异性：69%）和 CSA 减少 1.5mm 或更少（AUC=0.728，灵敏度：71%，特异性：70%）与严重烧心相关。
EndoFLIP 获得的 GEJ 开口动力学似乎与症状结果相关。当 Dmin 和 CSA 没有减少到定义的阈值时，术后 6 个月或更长时间更有可能出现严重烧心。这表明胃底折叠术可能不够紧，无法预防持续或复发性 GERD。
