Dominguez-Profeta Rebeca, Cheverie Joslin N, Blitzer Rachel R, Lee Arielle M, McClain Lauren, Broderick Ryan C, Sandler Bryan J, Jacobsen Garth R, Horgan Santiago, Kunkel David C
Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, CA, USA.
Division of Gastroenterology, Department of Medicine, University of California, San Diego, CA, USA.
Surg Endosc. 2021 Sep;35(9):5295-5302. doi: 10.1007/s00464-020-08013-5. Epub 2020 Oct 30.
Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA.
A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients.
Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m. 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12-14 beads) versus a larger MSA implant (15-17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026).
Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement.
磁括约肌增强术（MSA）为胃食管反流病提供了一种替代胃底折叠术的微创抗反流方法。MSA最常见的副作用是吞咽困难，这可能需要进行扩张甚至移除装置。通过MSA尺寸选择和术前动力研究，吞咽困难的发生率可能会降低。多次快速吞咽（MRS）是高分辨率食管测压（HRM）期间的一种激发性操作，用于评估蠕动储备。我们评估了预测MSA后吞咽困难发生的因素。
对一个前瞻性维护的数据库进行回顾性分析，确定接受MSA的患者。术前检查包括吞钡检查、食管胃十二指肠镜检查和食管测压。蠕动增强定义为MRS后远端收缩积分（DCI）与测压期间10次基线湿吞咽的平均DCI之比>1。收集所有患者的人口统计学数据、MSA植入尺寸和术后症状数据。
68例患者接受了MSA。平均年龄为51.7岁，平均体重指数为25.8kg/m。15例（22.1%）患者出现严重吞咽困难，需要内镜扩张。无吞咽困难患者的MRS蠕动增强明显更高（46.1%对6.3%，p=0.026）。33.3%需要扩张的患者在MRS后表现为完全没有平滑肌收缩（DCI=0）。预测MSA后吞咽困难的MRS/湿吞咽DCI比值为0.56。植入小尺寸（12 - 14颗珠子）MSA的患者与植入较大尺寸（15 - 17颗珠子）MSA的患者相比，术后吞咽困难发生率显著更高（58.5%对30.0%，p=0.026）。
足够的蠕动储备和较大的装置尺寸与MSA植入后吞咽困难发生率降低相关，且不影响抗反流屏障。在进行MSA放置前，应考虑在术前HRM期间对蠕动储备进行常规评估。
