Quantifying Factors Essential To The Integrity Of The Esophagogastric Junction During Anti-reflux Procedures.
*Dessislava Stefanova, *Jessica N. Limberg, *Timothy M. Ullmann, *Jessica W. Thiesmeyer, *Brendan M. Finnerty, *Toni Beninato, *Felice H. Schnoll-Sussman, *Philip O. Katz, Thomas J. Fahey, III, *Rasa Zarnegar
Weill Cornell Medicine, New York, NY
The lower esophageal sphincter (LES) and crural diaphragm constitute the intrinsic and extrinsic sphincters of the esophagogastric junction (EGJ), respectively. Surgical or endoscopic interventions to treat reflux attempt to restore the integrity of the EGJ. However, there are limited data on the relative contribution of critical steps during anti-reflux procedures to EGJ functional integrity. We aimed to quantify the contribution of these steps using EndoFLIP®, a novel technology that measures LES parameters in real-time.
Anti-reflux surgery was performed on 100 consecutive patients with pathologic reflux. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and LES length were collected using EndoFLIP®. Data were acquired pre-repair, post-diaphragmatic re-approximation with sub-diaphragmatic EGJ relocation, and post-sphincter augmentation. Confidence intervals (CI) were reported at 95%.
RESULTS: Patients underwent Nissen (46%), Toupet (40%), LINX (11%), or Hill-fundoplications (3%). After diaphragmatic re-approximation, DI decreased 0.97mm2/mmHg (-1.3, -0.67; p<0.0001), CSA decreased 15.0mm2 (-21.3, -8.7; p<0.0001), while LES length increased 7.9mm (6.0, 9.8; p<0.0001). After sphincter augmentation, DI decreased 0.49mm2/mmHg (-0.64, -0.34; p<0.0001) and CSA decreased 8.4mm2 (-12.8, -4.5; p=0.0002), while LES length increased 5.3mm (3.5, 7.1; p<0.0001). Diaphragmatic re-approximation had a higher percent contribution in distensibility (79% vs. 21%), CSA (75% vs. 25.0%), and length (60% vs. 40%) than sphincter augmentation.
Dynamic intraoperative monitoring demonstrates that diaphragmatic re-approximation and sub-diaphragmatic EGJ relocation has a greater effect on measurable parameters of functional EGJ integrity than sphincter augmentation. As such, anti-reflux procedures should address both for optimal patient outcomes.
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