Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
Surg Endosc. 2024 Nov;38(11):6894-6900. doi: 10.1007/s00464-024-11203-0. Epub 2024 Aug 29.
BACKGROUND: Dysphagia is a potential complication following anti-gastroesophageal reflux surgery (ARS), with challenging management. Endoscopic balloon dilation is recommended for patients with significant dysphagia from tight wraps or strictures. We aim to evaluate factors associated with the need for post-ARS dilation and the outcomes of balloon dilation. Additionally, we assessed the predictors of sustained clinical failure after dilation. METHODS: A retrospective analysis was conducted on patients who underwent robotic or laparoscopic ARS between January 2012 and April 2023. Patients were divided based on whether they received balloon dilation using a through-the-scope wire-guided dilator. Excluded were those with pre-existing achalasia, other dilation devices, or inadequate follow-up. RESULTS: Of 1002 patients, 69 underwent 94 postoperative dilations, and the remainder were controls. The dilation cohort was older (63.78 vs. 56.14 years, P = 0.032) and had more magnetic sphincter augmentations (MSA) (P = 0.004), a prior history of ARS (P = 0.039), and a higher rate of laparoscopic surgery (P = 0.009) compared to controls. Of all dilations, 54 (57.5%) patients reported immediate dysphagia improvement, and 39 (41.5%) had sustained improvement. Sixteen (23.2%) patients required reoperation, primarily for hiatal hernia recurrence or slipped wrap. Multivariable logistic regression showed that MSA (OR 0.04, 95% CI 0.01-0.46, P = 0.031) and requiring multiple dilations (OR 0.16, CI 0.03-0.68) predicted sustained dilation failure. CONCLUSIONS: Factors including older age, history of prior ARS, and MSA are correlated with higher post-ARS dilation rates. Although dilation improves symptoms in approximately half of patients initially, one-fourth may eventually require reoperation, mostly due to a slipped wrap or hernia recurrence. Thus, in cases of persistent dysphagia, consideration for surgical failure is important, and further imaging and workup are warranted. Patients who undergo MSA and those who have more than one dilation are more likely to experience dilation failure.
背景：抗胃食管反流手术（ARS）后可能会出现吞咽困难，其治疗具有挑战性。对于严重的吞咽困难伴有紧束或狭窄的患者，推荐使用内镜球囊扩张。我们旨在评估与 ARS 后扩张相关的因素以及球囊扩张的结果。此外，我们评估了扩张后持续临床失败的预测因素。
方法：对 2012 年 1 月至 2023 年 4 月间接受机器人或腹腔镜 ARS 的患者进行了回顾性分析。根据是否使用经内镜导丝引导的球囊扩张器进行球囊扩张将患者分为两组。排除了存在先天性食管下括约肌失弛缓症、其他扩张装置或随访不充分的患者。
结果：在 1002 例患者中，有 69 例患者接受了 94 次术后扩张，其余为对照组。扩张组年龄更大（63.78 岁 vs. 56.14 岁，P=0.032），接受磁括约肌增强术（MSA）的比例更高（P=0.004），有 ARS 既往史（P=0.039）和腹腔镜手术的比例更高（P=0.009）。所有扩张中，54 例（57.5%）患者报告吞咽困难立即改善，39 例（41.5%）患者持续改善。16 例（23.2%）患者需要再次手术，主要是因为食管裂孔疝复发或包裹滑脱。多变量逻辑回归显示，MSA（比值比 0.04，95%置信区间 0.01-0.46，P=0.031）和需要多次扩张（比值比 0.16，95%置信区间 0.03-0.68）预测持续扩张失败。
结论：包括年龄较大、既往 ARS 病史和 MSA 在内的因素与 ARS 后扩张率较高相关。虽然扩张最初使大约一半的患者症状改善，但四分之一的患者最终可能需要再次手术，主要是因为包裹滑脱或疝复发。因此，对于持续性吞咽困难，应考虑手术失败，并需要进一步的影像学和检查。接受 MSA 的患者和接受多次扩张的患者更有可能出现扩张失败。
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