Skip to main content
SpringerLink
Log in

More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation

  • 2020 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Introduction

Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA.

Materials and methods

A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients.

Results

Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m2. 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12–14 beads) versus a larger MSA implant (15–17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026).

Conclusion

Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1:
Figure 2:

Similar content being viewed by others

References

  1. Sandhu DS, Fass R (2018) Current trends in the management of gastroesophageal reflux disease. Gut Liver 12(1):7

    Article  CAS  Google Scholar 

  2. Toghanian S, Johnson DA, Stålhammar N-O, Zerbib F (2011) Burden of gastro-oesophageal reflux disease in patients with persistent and intense symptoms despite proton pump inhibitor therapy. Clin Drug Investig. https://doi.org/10.2165/11595480-000000000-00000

    Article  PubMed  Google Scholar 

  3. Broeders JA, Roks DJ, Ahmed Ali U, Draaisma WA, Smout AJ, Hazebroek EJ (2011) Laparoscopic anterior versus posterior fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. Ann Surg. https://doi.org/10.1097/SLA.0b013e31821d4ba0

    Article  PubMed  Google Scholar 

  4. Min MX, Ganz RA (2014) Update in procedural therapy for GERD - Magnetic sphincter augmentation, endoscopic transoralincisionless fundoplication vs laparoscopic nissen fundoplication. CurrGastroenterol Rep. https://doi.org/10.1007/s11894-014-0374-4

    Article  Google Scholar 

  5. Asti E, Aiolfi A, Lazzari V, Sironi A, Porta M, Bonavina L (2018) Magnetic sphincter augmentation for gastroesophageal reflux disease: review of clinical studies. Updates Surg. 70(3):323–330

    Article  Google Scholar 

  6. Sheu EG, Nau P, Nath B, Kuo B, Rattner DW (2015) A comparative trial of laparoscopic magnetic sphincter augmentation and Nissen fundoplication. SurgEndosc. https://doi.org/10.1007/s00464-014-3704-6

    Article  Google Scholar 

  7. Ganz RA, Edmundowicz SA, Taiganides PA, Lipham JC, Smith CCD, DeVault KR, Horgan S, Jacobsen G, Luketich JD, Smith CCD, Schlack-Haerer SC, Kothari SN, Dunst CM, Watson TJ, Peters J, Oelschlager BK, Perry KA, Melvin S, Bemelman WA, Smout AJPM, Dunn D (2016) Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. ClinGastroenterolHepatol. https://doi.org/10.1016/j.cgh.2015.05.028

    Article  Google Scholar 

  8. 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 CollSurg. https://doi.org/10.1016/j.jamcollsurg.2015.02.025

    Article  Google Scholar 

  9. Louie BE, Farivar AS, Shultz D, Brennan C, Vallières E, Aye RW (2014) Short-term outcomes using magnetic sphincter augmentation versus nissen fundoplication for medically resistant gastroesophageal reflux disease. Ann ThoracSurg. https://doi.org/10.1016/j.athoracsur.2014.04.074

    Article  Google Scholar 

  10. Aiolfi A, Asti E, Bernardi D, Bonitta G, Rausa E, Siboni S, Bonavina L (2018) Early results of magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis. Int J Surg 52:82–88

    Article  Google Scholar 

  11. Ganz RA, Peters JH, Horgan S, Bemelman WA, Dunst CM, Edmundowicz SA, Lipham JC, Luketich JD, Melvin WS, Oelschlager BK, Schlack-Haerer SC, Smith CD, Smith CC, Dunn D, Taiganides PA (2013) Esophageal sphincter device for gastroesophageal reflux disease. N Engl J Med. https://doi.org/10.1056/NEJMoa1205544

    Article  PubMed  Google Scholar 

  12. Wills VL, Hunt DR (2001) Dysphagia after antireflux surgery. Br J Surg 88(4):486–499

    Article  CAS  Google Scholar 

  13. Sims CA, Rattner DW (2006) Technical surgical failures: presentation, etiology and evaluation. In: Managing failed anti-reflux therapy

  14. Sato K, Awad ZT, Filipi CJ, Selima MA, Cummings JE, Fenton SJ, Hinder RA (2002) Causes of long-term dysphagia after laparoscopic Nissen fundoplication. J SocLaparoendoscSurg 6(1):35

    Google Scholar 

  15. Bonavina L, Demeester T, Fockens P, Dunn D, Saino G, Bona D, Lipham J, Bemelman W, Ganz RA (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):857–862

    Article  Google Scholar 

  16. Rona KA, Reynolds J, Schwameis K, Zehetner J, Samakar K, Oh P, Vong D, Sandhu K, Katkhouda N, Bildzukewicz N, Lipham JC (2017) Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias. SurgEndosc. https://doi.org/10.1007/s00464-016-5204-3

    Article  Google Scholar 

  17. Ayazi S, Zheng P, Zaidi AH, Chovanec K, Chowdhury N, Salvitti M, Komatsu Y, Omstead AN, Hoppo T, Jobe BA (2019) Magnetic sphincter augmentation and postoperative dysphagia: characterization, clinical risk factors, and management. J GastrointestSurg. https://doi.org/10.1007/s11605-019-04331-9

    Article  Google Scholar 

  18. Stoikes N, Drapekin J, Shaker A, Kushnir V, Brunt LM, Gyawali CP (2012) Motor response to multiple rapid swallows (MRS) can predict dysphagia in patients scheduled for laparoscopic antireflux surgery. SurgEndosc 26(12):3401–3407

    Google Scholar 

  19. Shaker A, Stoikes N, Drapekin J, Kushnir V, Brunt LM, Gyawali CP (2013) Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve. Am J Gastroenterol. https://doi.org/10.1038/ajg.2013.289

    Article  PubMed  PubMed Central  Google Scholar 

  20. Min YW, Shin I, Son HJ, Rhee PL (2015) Multiple rapid swallow maneuver enhances the clinical utility of high-resolution manometry in patients showing ineffective esophageal motility. Medicine. https://doi.org/10.1097/MD.0000000000001669

    Article  PubMed  PubMed Central  Google Scholar 

  21. Penagini R, Gyawali P (2019) Evaluation of esophageal contraction reserve using HRM in symptomatic esophageal disease. J ClinGastroenterol. https://doi.org/10.1097/MCG.0000000000001206

    Article  Google Scholar 

  22. Gyawali CP, Roman S, Bredenoord AJ, Fox M, Keller J, Pandolfino JE, Sifrim D, Tatum R, Yadlapati R, Savarino E, Azpiroz F, Babaei A, Bhatia S, Boeckxstaens G, Bor S, Carlson D, Castell D, Cicala M, Clarke J, De Bortoli N, Drug V, Frazzoni M, Holloway R, Kahrilas P, Kandulski A, Katz P, Katzka D, Mittal R, Mion F, Novais L, Patel A, Penagini R, Ribolsi M, Richter J, Salvador R, Savarino V, Serra J, Schnoll-Sussman F, Smout A, Soffer E, Sweis R, Tack J, Tolone S, Tutuian R, Vaezi M, Vela M, Woodland P, Wu J, Xiao Y, Zerbib F (2017) Classification of esophageal motor findings in gastro-esophageal reflux disease: conclusions from an international consensus group. NeurogastroenterolMotil 29(12):e13104

    Article  Google Scholar 

  23. Smith CD, Devault KR, Buchanan M (2014) Introduction of mechanical sphincter augmentation for gastroesophageal reflux disease into practice: early clinical outcomes and keys to successful adoption. J Am CollSurg. https://doi.org/10.1016/j.jamcollsurg.2013.12.034

    Article  Google Scholar 

  24. Scheffer RCH, Samsom M, Haverkamp A, Oors J, Hebbard GS, Gooszen HG (2005) Impaired bolus transit across the esophagogastric junction in postfundoplication dysphagia. Am J Gastroenterol. https://doi.org/10.1111/j.1572-0241.2005.42009.x

    Article  PubMed  Google Scholar 

  25. Marjoux S, Roman S, Juget-Pietu F, Robert M, Poncet G, Boulez J, Mion F (2012) Impaired postoperative EGJ relaxation as a determinant of post laparoscopic fundoplication dysphagia: a study with high-resolution manometry before and after surgery. SurgEndosc. https://doi.org/10.1007/s00464-012-2388-z

    Article  Google Scholar 

  26. Myers JC, Jamieson GG, Sullivan T, Dent J (2012) Dysphagia and gastroesophageal junction resistance to flow following partial and total fundoplication. J GastrointestSurg. https://doi.org/10.1007/s11605-011-1675-7

    Article  Google Scholar 

  27. Bonavina L, Saino GI, Bona D, Lipham J, Ganz RA, Dunn D, Demeester T (2008) Magnetic augmentation of the lower esophageal sphincter: results of a feasibility clinical trial. J GastrointestSurg. https://doi.org/10.1007/s11605-008-0698-1

    Article  Google Scholar 

  28. Kapadia S, Osler T, Lee A, Borrazzo E (2018) The role of preoperative high resolution manometry in predicting dysphagia after laparoscopic Nissen fundoplication. SurgEndosc. https://doi.org/10.1007/s00464-017-5932-z

    Article  Google Scholar 

  29. Bell RCW, Hanna P, Mills MR, Bowrey D (1999) Patterns of success and failure with laparoscopic to Toupet fundoplication. SurgEndosc. https://doi.org/10.1007/PL00009618

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, CA, USA

    Rebeca Dominguez-Profeta, Joslin N. Cheverie, Rachel R. Blitzer, Arielle M. Lee, Lauren McClain, Ryan C. Broderick, Bryan J. Sandler, Garth R. Jacobsen & Santiago Horgan

  2. Division of Gastroenterology, Department of Medicine, University of California, San Diego, CA, USA

    David C. Kunkel

Authors
  1. Rebeca Dominguez-Profeta
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joslin N. Cheverie
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rachel R. Blitzer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Arielle M. Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lauren McClain
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ryan C. Broderick
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Bryan J. Sandler
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Garth R. Jacobsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Santiago Horgan
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. David C. Kunkel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rachel R. Blitzer.

Ethics declarations

Disclosures

Drs. Dominguez-Profeta, Cheverie, Blitzer, Lee, McClain, and Broderick have no relevant conflicts of interest or financial ties to disclose. Dr. Sandler receives is a consultant for Intuitive Surgical and Boston Scientific. Dr. Jacobsen receives a teaching honorarium from Gore Medical. Dr. Horgan is a consultant for Intuitive Surgical, Medtronic, Stryker Corporation, and Fortimedix Surgical. Dr. Kunkel is a consultant for Pallete Life Sciences, Allergan, Salix Pharmaceuticals, QOL Medical, Redhill Biopharma, Shire (Takeda), Arena Pharmaceuticals, and Portola Pharmaceuticals.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dominguez-Profeta, R., Cheverie, J.N., Blitzer, R.R. et al. More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation. Surg Endosc 35, 5295–5302 (2021). https://doi.org/10.1007/s00464-020-08013-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-020-08013-5

Keywords

Search

Navigation