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Open Access 01-10-2021 | Dysphagia | 2020 SAGES Oral

Measurement of outflow resistance imposed by magnetic sphincter augmentation: defining normal values and clinical implication

Authors: Shahin Ayazi, Andrew D. Grubic, Ping Zheng, Ali H. Zaidi, Katrin Schwameis, Adam C. Alleyne, Brittney M. Myers, Ashten N. Omstead, Blair A. Jobe

Published in: Surgical Endoscopy | Issue 10/2021

Abstract

Introduction

No manometric criteria have been defined to select patients for magnetic sphincter augmentation (MSA). The first step to establish such criteria is to measure the outflow resistance at esophagogastric junction (EGJ) imposed by MSA. This resistance needs to be overcome by the esophageal contraction in order for the esophagus to empty and to avoid postoperative dysphagia. This study was designed to measure the outflow resistance caused by MSA in patients free of postoperative dysphagia.

Methods

Records of the patients who underwent MSA in our institution were reviewed. A group of MSA patients with excellent functional outcome, who were free of clinically significant postoperative dysphagia, were selected. These patients then underwent high-resolution impedance manometry (HRIM) at a target date of 1 year after surgery. The outflow resistance was measured by the esophageal intrabolus pressure (iBP) recorded 2 cm proximal to the lower esophageal sphincter (LES).

Results

The study population consisted of 43 patients. HRIM was performed at mean of 20.4 (10.4) months after surgery. The mean (SD) amplitude of the iBP was 13.5 (4.3) before surgery and increased to 19.1 (5.6) after MSA (p < 0.0001). Patients with a smaller size LINX device (≤ 14 beads) had a similar iBP when compared to those with a larger device (> 15 beads) [19.7 (4.5) vs. 18.4 (5.9), p = 0.35]. There was a significant correlation between the iBP and % incomplete bolus clearance [Spearman R: 0.44 (95% CI 0.15–0.66), p = 0.0032]. The 95th percentile value for iBP after MSA was 30.4 mmHg.

Conclusion

The EGJ outflow resistance measured by iBP is increased after MSA. The upper limit of normal for iBP is 30 mmHg in this cohort of patients who were free of dysphagia after MSA. This degree of resistance needs to be overcome by distal esophageal contraction and will likely be requisite to prevent persistent postoperative dysphagia.

Bonavina L, DeMeester T, Fockens P, Dunn D, Saino G, Bona D et al (2010) Laparoscopic sphincter augmentation device eliminates reflux symptoms and normalizes esophageal acid exposure: one- and 2-year results of a feasibility trial. Ann Surg 252(5):857–862CrossRef

Bell R, Lipham J, Louie BE, Williams V, Luketich J, Hill M et al (2020) Magnetic sphincter augmentation superior to proton pump inhibitors for regurgitation in a 1-year randomized trial. Clin Gastroenterol Hepatol 10:1736–1743.e2CrossRef

Ayazi S, Zheng P, Zaidi AH, Chovanec K, Salvitti M et al (2020) Clinical outcomes and predictors of favorable result after laparoscopic magnetic sphincter augmentation: single-institution experience with more than 500 patients. J Am Coll Surg 230(5):733–743CrossRef

Reynolds JL, Zehetner J, Wu P, Shah S, Bildzukewicz N, Lipham JC (2015) Laparoscopic magnetic sphincter augmentation vs laparoscopic Nissen fundoplication: a matched-pair analysis of 100 patients. J Am Coll Surg 221(1):123–128CrossRef

Ganz RA, Peters JH, Horgan S, Bemelman WA, Dunst CM (2013) Esophageal sphincter device for gastroesophageal reflux disease. N Engl J Med 368(8):719–727CrossRef

Ayazi S, DeMeester SR, Hagen JA, Zehetner J, Bremner RM, Lipham JC et al (2019) Clinical significance of esophageal outflow resistance imposed by a Nissen fundoplication. J Am Coll Surg 229(2):210–216CrossRef

Myers JC, Jamieson GG, Sullivan T, Dent J (2012) Dysphagia and gastroesophageal junction resistance to flow following partial and total fundoplication. J Gastrointest Surg 16(3):475–485CrossRef

Hoppo T, Sanz AF, Nason KS, Carroll TL, Rosen C, Normolle DP, Shaheen NJ et al (2012) How much pharyngeal exposure is “normal”? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg 16(1):16–24CrossRef

Ayazi S, Lipham JC, Portale G, Peyre CG, Streets CG et al (2009) Bravo catheter-free pH monitoring: normal values, concordance, optimal diagnostic thresholds, and accuracy. Clin Gastroenterol Hepatol 7(1):60–67CrossRef

10.

Velanovich V (2007) The development of the GERD-HRQL symptom severity instrument. Dis Esophagus 20(2):130–134CrossRef

11.

Velanovich V, Vallance SR, Gusz JR, Tapia FV, Harkabus MA (1996) Quality of life scale for gastroesophageal reflux disease. J Am Coll Surg 183(3):217–224PubMed

12.

Belafsky PC, Postma GN, Koufman JA (2002) Validity and reliability of the reflux symptom index (RSI). J Voice 16(2):274–277CrossRef

13.

Ayazi S, Crookes PF (2010) High-resolution esophageal manometry: using technical advances for clinical advantages. J Gastrointest Surg 14(Suppl 1):S24–S32CrossRef

14.

Ayazi S, Zheng P, Zaidi AH, Chovanec K, Chowdhury N, Salvitti M et al (2020) Magnetic sphincter augmentation and postoperative dysphagia: characterization, clinical risk factors, and management. J Gastrointest Surg 24(1):39–49CrossRef

15.

Warren HF, Louie BE, Farivar AS, Wilshire C, Aye RW (2017) Manometric changes to the lower esophageal sphincter after magnetic sphincter augmentation in patients with chronic gastroesophageal reflux disease. Ann Surg 266(1):99–104CrossRef

16.

Riva CG, Siboni S, Sozzi M, Lazzari V, Asti E, Bonavina L (2020) High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease. Neurogastroenterol Motil 32(3):e13750CrossRef

17.

Ayazi S (2020) Quantifying esophagogastric junction barrier competency using high-resolution manometry. J Am Coll Surg 230(5):755–757CrossRef

18.

Roman S, Gyawali CP, Xiao Y, Pandolfino JE, Kahrilas PJ (2014) The Chicago classification of motility disorders: an update. Gastrointest Endosc Clin N Am 24(4):545–561CrossRef

19.

Kahrilas PJ, Bredenoord AJ, Fox M et al (2015) The Chicago classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 27:160–174CrossRef

20.

Cook IJ (1993) Cricopharyngeal function and dysfunction. Dysphagia 8:244–251CrossRef

21.

Shaw DW, Cook IJ, Gabb M et al (1995) Influence of normal aging and oral-pharyngeal and upper esophageal sphincter function during swallow. Am J Physiol 268:389–396CrossRef

22.

Lin Z, Yim B, Gawron A, Imam H, Kahrilas PJ, Pandolfino JE (2014) The four phases of esophageal bolus transit defined by high-resolution impedance manometry and fluoroscopy. Am J Physiol Gastrointest Liver Physiol 307(4):G437–G444CrossRef

23.

Quader F, Reddy C, Patel A, Gyawali CP (2017) Elevated intrabolus pressure identifies obstructive processes when integrated relaxation pressure is normal on esophageal high-resolution manometry. Am J Physiol Gastrointest Liver Physiol 313(1):G73–G79CrossRef

24.

Bonavina L, DeMeester TR, Ganz RA (2012) LINX(™) Reflux Management System: magnetic sphincter augmentation in the treatment of gastroesophageal reflux disease. Expert Rev Gastroenterol Hepatol 6(6):667–674CrossRef

25.

Ganz RA, Gostout CJ, Grudem J, Swanson W, Berg T, DeMeester TR (2008) Use of a magnetic sphincter for the treatment of GERD: a feasibility study. Gastrointest Endosc 67(2):287–294CrossRef

26.

Ganz RA (2017) A modern magnetic implant for gastroesophageal reflux disease. Clin Gastroenterol Hepatol 15(9):1326–1337CrossRef

27.

Kahrilas PJ, Lin S, Manka M, Shi G, Joehl RJ (2000) Esophagogastric junction pressure topography after fundoplication. Surgery 127(2):200–208CrossRef

28.

Jeyasingham K (1994) What is the histology of an esophageal stricture before and after dilatation? In: Giuli R, Tytgat GNJ, DeMeester TR (eds) The esophageal mucosa. Elsevier Science BV, Amsterdam, p 335

29.

Hoscheit M, Gabbard S (2019) Elevated intrabolus pressure predicts abnormal timed barium esophagram in esophagogastric junction outflow obstruction. J Neurogastroenterol Motil 25(4):521–524CrossRef

Title: Measurement of outflow resistance imposed by magnetic sphincter augmentation: defining normal values and clinical implication
Authors: Shahin Ayazi
Andrew D. Grubic
Ping Zheng
Ali H. Zaidi
Katrin Schwameis
Adam C. Alleyne
Brittney M. Myers
Ashten N. Omstead
Blair A. Jobe
Publication date: 01-10-2021
Publisher: Springer US
Keywords: Dysphagia
Dysphagia
Dysphagia
Published in: Surgical Endoscopy / Issue 10/2021
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-020-08068-4

At a glance: The STEP trials

Springer Medicine

Measurement of outflow resistance imposed by magnetic sphincter augmentation: defining normal values and clinical implication

Abstract

Introduction

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

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