Providence Portland Medical Center, 4805 NE Glisan Street, Suite 6N60, Portland, OR, 97213, USA.
Center for Advanced Surgery, The Oregon Clinic, Portland, OR, 97213, USA.
Surg Endosc. 2023 May;37(5):3982-3993. doi: 10.1007/s00464-022-09507-0. Epub 2022 Sep 6.
The aim was to evaluate the clinical significance of multiple rapid swallows (MRS) during high-resolution manometry (HRM) prior to fundoplication. Despite pre-operative HRM, up to 38% of patients report post-fundoplication dysphagia. Suggestion that MRS improves prediction of dysphagia after fundoplication has not been investigated when using a tailored approach. We hypothesize response to MRS is predictive of dysphagia after tailored fundoplication.
A retrospective cohort study was performed on patients undergoing HRM with MRS provocation 5/2019-7/2021 at a single institution. Patients who underwent subsequent index laparoscopic fundoplication, without peptic stricture or achalasia, were included. After performing standard 10-swallow HRM, MRS provocation was performed. Patient-reported dysphagia frequency scores were collected at initial consultation and post-operative follow-up. At least weekly symptoms were considered clinically significant. Normal MRS response was defined as adequate deglutitive inhibition and MRS contractile response. Fundoplications were tailored based on standard HRM values.
HRM was performed in 1201 patients, 220 met inclusion criteria. Clinically significant pre-operative dysphagia was reported by 85 (38.6%). Patients undergoing partial fundoplication (n = 123, 55.9%) had lower mean distal contractile integer, distal esophageal contraction amplitude, and percent peristalsis (p < 0.005). Post-operatively, 120 (54.5%) were without dysphagia, 59 (26.8%) had improved dysphagia, 26 (11.8%) had unchanged dysphagia, and 15 (6.8%) reported new dysphagia. There was no statistical difference in early or late dysphagia outcome between tailored fundoplication groups (p = 0.69). On univariate and multivariate analysis, neither MRS response, nor standard HRM metrics were significantly associated with post-operative dysphagia. Younger age (OR 0.96, 95% CI 0.94-0.986, p = 0.042) and the presence of pre-operative dysphagia (OR 2.54, 95% CI 1.17-5.65, p = 0.015) were significant predictors of post-operative dysphagia.
The risk of clinically significant dysphagia post-fundoplication is low when using a tailored approach based on standard HRM metrics. Additional data provided by MRS does not add to surgical decision-making using the investigated approach.
本研究旨在评估在胃食管反流病（GERD）术前高分辨率测压（HRM）期间进行多次快速吞咽（MRS）的临床意义。尽管进行了术前 HRM，但仍有 38%的患者报告术后存在吞咽困难。有研究表明，在采用个体化治疗方法时，MRS 可改善胃底折叠术后吞咽困难的预测效果，但这一观点尚未得到验证。我们假设 MRS 反应可预测个体化胃底折叠术后的吞咽困难。
本研究采用回顾性队列研究，纳入了 2019 年 5 月至 2021 年 7 月在单家医疗机构接受 HRM 联合 MRS 激发试验的患者。研究对象为接受后续标准腹腔镜胃底折叠术（无消化性狭窄或贲门失弛缓症）的患者。在进行标准的 10 次吞咽 HRM 后，进行 MRS 激发试验。在初始就诊和术后随访时，收集患者报告的吞咽困难频率评分。每周至少出现一次症状被认为具有临床意义。正常的 MRS 反应定义为充分的吞咽抑制和 MRS 收缩反应。胃底折叠术采用基于标准 HRM 值的个体化方法。
共有 1201 例患者接受了 HRM 检查，其中 220 例符合纳入标准。85 例（38.6%）患者术前报告存在有临床意义的吞咽困难。接受部分胃底折叠术（n=123，55.9%）的患者的远端收缩积分、远端食管收缩幅度和蠕动百分比均较低（p<0.005）。术后，120 例（54.5%）患者无吞咽困难，59 例（26.8%）患者吞咽困难改善，26 例（11.8%）患者吞咽困难无变化，15 例（6.8%）患者出现新的吞咽困难。个体化胃底折叠术各组之间早期或晚期吞咽困难结局无统计学差异（p=0.69）。在单因素和多因素分析中，MRS 反应和标准 HRM 指标均与术后吞咽困难无显著相关性。年龄较小（OR 0.96，95%CI 0.94-0.986，p=0.042）和术前存在吞咽困难（OR 2.54，95%CI 1.17-5.65，p=0.015）是术后吞咽困难的显著预测因素。
采用基于标准 HRM 指标的个体化方法时，胃底折叠术后发生有临床意义的吞咽困难的风险较低。在采用所研究的方法时，MRS 提供的额外数据对手术决策没有帮助。
