Surgical Endoscopy (2020) 34:2608–2612 and Other Interventional Techniques

https://doi.org/10.1007/s00464-019-07031-2

2019 SAGES ORAL

Laparoscopic Nissen fundoplication improves disease‑specific quality

of life in patients with gastroesophageal reflux disease and functional
gastroesophageal outflow obstruction
Noah J. Switzer1   · Carla Holcomb1 · Anahita D. Jalilvand1 · Monet Mcnally1 · Alexandra Power1 · Patricia Belle1 ·
Kyle A. Perry1,2

Received: 24 April 2019 / Accepted: 19 July 2019 / Published online: 26 July 2019
© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Introduction  The optimal management of functional esophagogastric junction outflow obstruction (EJOO) remains con-
troversial particularly in the setting of concomitant gastroesophageal reflux disease (GERD). There remains a paucity of
data regarding the outcomes of laparoscopic Nissen fundoplication (LNF) in this patient population. We hypothesized that
GERD patients with manometric findings of EJOO on preoperative manometry do not have increased rates of postoperative
dysphagia compared to those with normal or hypotensive LES pressures.
Materials and methods  This retrospective cohort study of patients undergoing LNF for GERD compared outcomes in patients
with and without functional EJOO (fEJOO). The outcomes of interest included disease-specific quality of life improvement,
dysphagia scores, and the need for endoscopic dilation following fundoplication.
Results  Two hundred and eleven patients underwent LNF for GERD and 15 (7.1%) were classified as having fEJOO. Base-
line GERD-HRQL [30.0 (21.5–37) vs. 31 (21–37), p = 0.57] were similar between fEJOO and control patients, respectively.
There was no difference in baseline dysphagia scores [3.5 (2–5) vs. 2.0 (1–4), p = 0.64] between the two groups. Postoperative
GERD-HRQL [5.0 (2–13) vs. 4.0 (1–8), p = 0.59] scores did not differ between fEJOO and control patients at 6-week follow-
up. One year after surgery, GERD-HRQL [8.0 (3–9) vs. 4.5 (2–13), p = 0.97] did not differ between groups. Dysphagia rates
were similar at 6-week (p = 0.78) and 1-year follow-ups (p = 0.96). The need for dilation at 1 year following fundoplication
was similar in both cohorts (13%, p = 0.96).
Conclusion  GERD patients with functional EJOO achieved similar improvements in disease-specific quality of life without
increased incidence of dysphagia postoperatively.

Keywords  GERD · Nissen · Esophagogastric junction outflow obstruction · Dysphagia

Hypertensive lower esophageal sphincter (LES) is a primary accompanied by acid reflux, and that patients presenting
esophageal motility disorder that was initially described in with symptomatic gastroesophageal reflux disease (GERD)
1960 [1]. This finding is most often associated with dys- and manometric findings of hypertensive LES may achieve
phagia and chest pain and may represent a condition akin to better benefit from laparoscopic Nissen fundoplication
achalasia and may benefit from treatments aimed at reduc- (LNF) rather than from esophageal myotomy [3, 4].
ing LES pressure, including surgical myotomy [2]. How- The advent of high-resolution manometry has led to a
ever, it has also been shown that hypertensive LES is often reclassification of esophageal motility disorders based on
these parameters, including functional esophagogastric
junction outflow obstruction (EJOO) [5]. This condition
* Kyle A. Perry has an incidence of 3–11 percent, and is characterized by
kyle.perry@osumc.edu the manometric finding of elevated integrated relaxation
1
Division of Surgery, The Ohio State University, Columbus, pressure (IRP) of greater than 15 mmHg in the setting of
OH, USA preserved esophageal peristalsis [5–7]. EJOO can represent
2
Division of General and Gastrointestinal Surgery, N729 Doan a primary esophageal motility finding or a secondary find-
Hall, 410 West 10th Avenue, Columbus, OH 43210, USA ing related to hiatal hernia, stricture, tumor, eosinophilic

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esophagitis, or esophageal varices [8]. Functional or idi- reflux symptom scale (GERSS) and disease-specific quality
opathic EJOO (fEJOO) is associated with no structural or of life as measured by the gastroesophageal reflux disease
anatomic abnormality. health-related quality of life (GERD HRQL) questionnaire
Similar to those with hypertensive LES, patients with [10]. Patients completed the questionnaire preoperatively
fEJOO often present with symptoms of dysphagia and in the clinic, again at their early postoperative follow-up
chest pain, but also may present with symptoms and objec- appointment (4–8 weeks) and were then contacted by tel-
tive findings of GERD [7]. Studies have shown that patients ephone for long-term follow-up results. Secondary outcome
presenting with fEJOO and minimal symptoms can be man- variables included dysphagia scores and need for endoscopic
aged expectantly and those with significant dysphagia or dilation to manage postoperative dysphagia.
chest pain may benefit from management strategies aimed at
reducing LES pressure including smooth muscle relaxants, Statistical analysis
botulinum toxin injection, pneumatic dilation, and surgical
myotomy [8, 9]. There remains a paucity of data, however, Statistical analyses were performed using Stata 15 statis-
regarding the management of patients with symptomatic tical software (Statacorp LLC, College Station, Tx). Data
GERD in the setting of manometric findings of fEJOO. are presented as mean ± standard deviation (SD), median
We hypothesized that similar to those with GERD and (IQR), or number (%) as appropriate. Differences between
hypertensive LES, patients with manometric findings of continuous and categorical variables were evaluated using
fEJOO in the setting of symptomatic GERD would derive Mann–Whitney U-test and Chi-square test, respectively. A p
similar improvements in patient-reported outcomes follow- value of < 0.05 was considered statistically significant.
ing LNF as those with normal LES function. We tested this
hypothesis in a retrospective cohort study with a primary
outcome of improvement in disease-specific quality of life Results
following LNF. Secondary outcomes included postoperative
dysphagia scores and need for endoscopic dilation. Two hundred and eleven patients meeting the inclusion and
exclusion criteria underwent LNF for GERD during the
study period and were included in this study. Fifteen (7.1%)
Materials and methods patients met criteria for fEJOO and 196 (92.9%) represented
the control arm for the study.
Patients There were no differences in patient age (p = 0.82), BMI
(p = 0.12), race,(p = 0.52), or insurance status (p = 0.36)
We performed a retrospective cohort study of patients under- between the two groups (Table 1). There were no signifi-
going LNF for management of GERD at the Ohio State cant differences in presenting predominant complaints.
University Wexer Medical Center between 2009 and 2017. All patients in the fEJOO group had typical symptoms of
All patients underwent preoperative endoscopy, esophageal GERD, expressing either heartburn or regurgitation, com-
pH monitoring, and esophageal manometry. Patients with pared with 95% (n = 187) in the control arm. Patients in both
potential secondary causes of EJOO including redo opera- groups had similar incomplete bolus clearance of approxi-
tion, paraesophageal hiatal hernia, and those without the mately 40% (p = 0.85) and symptom association probability
manometric data required to diagnose EJOO or hypertensive in reference to heartburn (p = 0.64). Baseline GERD-HRQL
LES were excluded. Demographic variables, questionnaire [30.0 (21.5–37) vs. 31 (21–37), p = 0.57] and GERSS [36.5
results, diagnostic tests, and outcomes were extracted from (31–54) vs. 40.0 (26–50), p = 0.78] scores were similar
a prospectively maintained database approved by the insti- between fEJOO and control patients, respectively. There was
tutional review board. no difference in baseline dysphagia scores [3.5 (2–5) vs. 2.0
Patients were divided into two groups: fEJOO versus (1–4), p = 0.64] between the two groups (Table 1).
control. Functional EJOO was defined as an IRP above Following LNF, GERD-HRQL and GERSS scores
15 mmHg or elevated mean LES residual pressure with pre- improved significantly in both groups. Postoperative GERD-
served peristalsis, not meeting criteria for achalasia. The HRQL [5.0 (2–13) vs. 4.0 (1–8), p = 0.59] and GERSS [11.0
control group included all patients who underwent LNF for (0–15) vs. 6.0 (1–13.5), p = 0.71] scores did not differ sig-
GERD and did not meet criteria for functional EJOO. nificantly between those with and without fEJOO, respec-
tively (Table 2). At 1-year follow-up, GERD-HRQL [8.0
Primary and secondary outcomes (3–9) vs. 4.5 (2–13), p = 0.97] and GERSS [20.0 (4–23) vs.
8.0 (1–22), p = 0.82] scores did not differ between groups.
The primary outcomes for this study were improvement in Early postoperative dysphagia rates were similar for
GERD symptoms as assessed using the gastroesophageal those with [1.0 (0–3)] and without fEJOO [1.0 (0–2),

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Table 1  Demographics, Variable FEJOO (N = 15) Control (N = 196) P-value

baseline symptom scores,
and results of reflux testing Age, SD (years) 51.8 ± 12.9 51.0 ± 12.9 0.82
for patients with and without
BMI, SD (kg/m2) 33.1 ± 5.4 30.8 ± 5.1 0.12
functional EJOO
Race, N(%) 0.52
Caucasian 14 (93.3) 165 (84.6)
African American 0 (0) 15 (7.7)
Other 1 (6.7) 15 (7.7)
Insurance status, N(%) 0.36
Medicare 2 (13.3) 50 (25.6)
Medicaid 0 (0) 4 (2.1)
Private 13 (86.7) 127 (65.1)
Self-pay 0 (0) 14 (7.2)
ASA category, SD 2.6 ± 0.6 2.4 ± 0.5 0.26
Predominant symptoms
Typical GERD, n (%)
Heartburn 14 (93) 160 (81)
Regurgitation 12 (80) 132 (67)
Either 15 (100) 187 (95)
Atypical GERD, n (%) 0.22
Dysphagia 2 (13) 62 (31)
Cough 5 (33) 54 (28)
Chest pain 5 (33) 57 (29)
DeMeester score, mean ± SD 49.9 ± 32.6 44.9 ± 28.8 0.55
% peristalsis, mean ± SD 81.6 ± 18.2 86.5 ± 16.8 0.28
% incomplete bolus clearance ±SD 39.4 ± 27.4 37.5 ± 30.6 0.85
Symptom association probability,  % ±SD 93.0 ± 6.1 89.0 ± 23.8 0.63
Heartburn
Baseline dysphagia, median (IQR) 3.5 (2–5) 2.0 (1–4) 0.64
Baseline GERD-HRQL score, median (IQR) 30.0 (21.5–37) 31.0 (21–37) 0.56
Baseline GERSS score, median (IQR) 36.5 (31–54) 40.0 (26–40) 0.78

Table 2  Postoperative outcomes Variable FEJOO (N = 15) Control (N = 196) Probability

of laparoscopic Nissen
fundoplication in patients with 6-week GERD-HRQL score, median (IQR) 5.0 (2–13) 4.0 (1–8) 0.59
and without functional EJOO
6-week GERSS score, median (IQR) 11.0 (0–15) 6.0 (1–13.5) 0.71
6-week dysphagia score, median (IQR) 1.0 (0–3) 1.0 (0–2) 0.78
1-year GERD-HRQL score, median (IQR) 8 (3–9) 4.5 (2–13) 0.97
1-year GERSS score, median (IQR) 20 (4–23) 8 (1–22) 0.82
1-year dysphagia score, median (IQR) 0.5 (0–2.5) 0.0 (0–2) 0.74
Endoscopic dilation, n (%) 2 (13.3) 27 (13.8) 0.96

p = 0.78]. At 1-year follow-up, dysphagia scores did Discussion

not differ between the groups [0.5 (0–2.5) vs. 0.0 (0–2),
p = 0.96]. During the 1st year following LNF, 2 (13.3%) Functional EJOO represents a heterogenous condition that
patients in the fEJOO group underwent endoscopic dila- may present as a condition analogous to achalasia with
tion for management of dysphagia compared to 27 (13.8%) symptoms of dysphagia and chest pain, but may also pre-
patients in the control groups (p = 0.96, Table  2). No sent in conjunction with severe symptomatic GERD. The
patient in either group required revision to a partial fun- aim of the current study was to assess the role of LNF in
doplication, botulinum toxin injection, or surgical myot- patients with symptomatic GERD and manometric findings
omy during the study period.

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consistent with fEJOO. This represents a distinct subgroup Our study is limited by observational design and the small
population of reflux patients with incidentally discovered number of patients meeting the manometric diagnosis of
elevated LES pressures on manometry. We found that fEJOO. Also, this cohort represents a carefully selected
GERD can be successfully managed in this patient cohort cohort of patients with findings of fEJOO without signifi-
with laparoscopic fundoplication without specific manage- cant baseline dysphagia complaints, and the finding that fun-
ment aimed at reducing LES pressure. This approach led doplication does not carry an increased risk of significant
to substantial improvements in disease-specific quality of postoperative dysphagia should be generalized to the broader
life without increased rates of postoperative dysphagia or fEJOO population. Also, the study endpoint of 1 year does
need for further endoscopic or surgical intervention during not allow us to assess the long-term impact of fundoplication
the first year after surgery. in these patients, and the natural history of functional EJOO
Currently, there is no consensus as to the best man- in these patients remains poorly understood and, therefore,
agement of functional EJOO due in part to the infancy requires further evaluation in longitudinal studies.
of the diagnosis, the relatively few numbers of patients
afflicted, and the heterogeneity of this patient population
[11]. The presenting symptoms in patients with findings Conclusion
of fEJOO may represent the most important considera-
tion when considering treatment strategies for this condi- GERD patients with functional EJOO or hypertensive LES
tion. Asymptomatic or minimally symptomatic functional achieved postoperative outcomes following LNF similar to
EJOO can be managed effectively with observation alone, those for patients without elevated LES pressures. There was
with or without a therapeutic trial of botox, and nearly no increased risk for dysphagia or the need for endoscopic
half of these patients will have spontaneous resolution of dilation in the first year following surgery. These results
symptoms within 6 months [5, 8, 11, 12]. suggest that LNF can be safely performed with excellent
The most common clinical presentation for patients results in carefully selected patients with objectively con-
with fEJOO is significant dysphagia or chest pain. These firmed GERD and manometric findings of functional EJOO.
patients were excluded from the current study as this con-
dition likely represents a primary esophageal motility dis- Acknowledgements None.
order similar to achalasia. In this clinical scenario, studies
have reported success of interventions aimed at reducing Funding  No funding was provided for this manuscript
LES pressure including botulinum toxin injection, pneu-
matic dilation, or surgical myotomy [6, 13]. In our study Compliance with ethical standards 
cohort of fEJOO patients presenting with predominant
Disclosures  Drs. Noah J Switzer, Carla Holcomb, Anahita D Jalilvand,
reflux symptoms and objective testing demonstrating path-
Monet Mcnally, Alexandra Power, Patricia Belle, and Kyle A Perry
ologic acid reflux, the incidence of dysphagia was 13% have no conflicts of interest or financial ties to disclose.
compared to the overall rate of greater than 50% for all
patients with fEJOO reported in the literature suggesting
that this represents a fundamentally different patient popu-
lation from those with primary esophageal dysmotility. References
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