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Does Ineffective Esophageal Motility on Manometry Determine Outcomes After PEH Repair?
Ayesha Siddiq
*, Nicholas Catanzaro, Nicolette Winder, Hamza N. Chatha, Patrick Wieland, Saher Z. Khan, Samuel Zolin, Jeffrey Marks, Joshua Lyons, Leena Khaitan
General Surgery, University Hospitals Cleveland - Case Western Reserve University School of Medicine, Cleveland, OH
IntroductionAlthough the utility of preoperative esophageal manometry prior to paraesophageal hernia repair (PEHR) is controversial, those with ineffective esophageal motility (IEM) may benefit. Whether IEM independently predicts outcomes post-operatively remains unclear. We aim to evaluate the association between IEM and postoperative outcomes after PEHR.
MethodsUtilizing our institutional database, we identified adult patients who had elective minimally invasive PEHR (2016-2023). Patients with prior PEHR, missing preoperative esophageal manometry or insufficient follow-up data were excluded. The primary exposure was preoperative IEM. The primary outcome was documented radiographic or endoscopic hernia recurrence; secondary was postoperative symptoms.
Unadjusted comparisons used t-tests, chi-square, or Fisher's tests. Multivariable logistic regression evaluated association between IEM and outcomes, adjusting for age, sex, BMI, ASA, operative approach, and fundoplication type.
Results508 patients met inclusion criteria, 88 (17.32%) had preoperative IEM. Baseline characteristics are shown in table 1. IEM group had a significantly lower BMI (28.26 ± 5.18 vs 30.61± 5.52) and were more likely to undergo fundoplication (78.16% vs 66.34%), particularly Toupet (56.98% vs 23.00%) or Dor (11.63% vs 2.18%).
Unadjusted analyses showed no significant differences in outcomes between groups. On adjusted multivariable analysis, preoperative IEM was not independently associated with hernia recurrence (OR-1.534, 95% CI 0.80-2.95, p=0.200) or redo surgery (OR-1.47, 95% CI 0.45-4.85, p=0.526), while increasing age was associated with higher odds of recurrence (OR-1.02, 95% CI 1.00-1.05, p=0.035).
Persistent dysphagia (>30 days postoperatively) was trended higher in the IEM group, and were more likely to have a procedure for management (table 2).
ConclusionThis study does not demonstrate an association between IEM on preoperative manometry and postoperative recurrence. However, those with IEM are more likely to have persistent dysphagia and may require endoscopic management. This motility finding can be helpful in managing expectations and outcomes following PEHR.
Baseline patient and operative characteristics stratified by preoperative ineffective esophageal motility (IEM)
| Characteristic | Overall (N =508) | No IEM (N =420) | IEM (N = 88) | p-value |
| Age, years | 59.06 ± 13.09 | 58.74 ± 12.60 | 60.57 ± 13.55 | 0.221 |
| Female sex, n (%) | 258 (74.78%) | 216 (75.00%) | 42 (73.68%) | 0.834 |
| BMI, kg/m2 | 30.20 ± 5.53 | 30.61 ± 5.52 | 28.26 ± 5.18 | <0.001 |
| ASA III-V, n (%) | 281 (58.79%) | 230 (57.64%) | 51 (64.56%) | 0.254 |
| Operative approach, n (%) | | | | 0.648 |
| Laparoscopic, n (%) | 467 (92.66%) | 388 (93.05%) | 79 (90.80%) | |
| Robotic, n (%) | 36 (7.14%) | 28 (6.71%) | 8 (9.20%) | |
| Thoracoscopic, n (%) | 1 (0.20%) | 1 (0.24%) | 0 (0%) | |
| Fundoplication performed, n (%) | 342 (68.40%) | 274 (66.34%) | 68 (78.16%) | 0.031 |
| Nissen, n (%) | 178 (35.67%) | 170 (41.6%) | 8 (9.30%) | <0.001 |
| Toupet, n (%) | 144 (28.86%) | 95 (23.00%) | 49 (56.98%) | <0.001 |
| Dor, n (%) | 19 (3.81%) | 9 (2.18%) | 10 (11.63%) | <0.001 |
| None, n (%) | 158 (31.66%) | 139 (33.66%) | 19 (22.09%) | <0.001 |
| Mesh use, n (%) | 123 (24.50%) | 107 (25.78%) | 16 (18.39%) | 0.145 |
| Collis gastroplasty, n (%) | 2 (0.40%) | 1 (0.24%) | 1 (1.16%) | 0.314 |
| Any concomitant procedure, n (%) | 125 (25.46%) | 102 (25.12%) | 23 (27.06%) | 0.710 |
| GERD >30 days postop, n (%) | 37 (7.31%) | 31 (7.40%) | 6 (6.90%) | 0.870 |
| Dysphagia >30 days postop, n (%) | 65 (12.82%) | 49 (11.69%) | 16 (18.18%) | 0.098 |
Values are presented as mean ± SD or number (percentage), as appropriate.
Type of intervention for dysphagia
| Type of intervention for dysphagia | Overall (N =29) | No IEM (N =21) | IEM (N = 8) | P=0.203 |
| EGD with dilation | 11 (37.93%) | 7 (33.33%) | 4 (50.00%) | |
| EGD with botulinum toxin injection | 1 (3.45%) | 0 (0.00%) | 1 (12.50%) | |
| PPI Therapy | 7 (24.14%) |
5 (23.81%) | 2 (25.00%) | |
| Other | 10 (34.38%) | 9 (42.86%)
| 1 (12.50%) | |
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