The Impact of Ineffective Esophageal Motility on Patients Undergoing Magnetic Sphincter Augmentation

Abstract

Objective: To evaluate and characterize outcomes of MSA in patients with IEM. Summary Background Data: MSA improves patients with gastroesophageal reflux and normal motility. However, many patients have IEM, which could impact the outcomes of MSA and discourage use. Methods: An international, multi-institutional case control study of IEM patients undergoing MSA matched to normal patients was performed. Primary outcomes were new onset dysphagia and need for postoperative interventions.Results: A total of 105 IEM patients underwent MSA with matching controls. At 1 year after MSA: GERD-Health Related Quality of Life was similar; DeMeester scores in IEM patients improved to 15.7 and 8.5 in controls (P = 0.021); and normalization of the DeMeester score for IEM = 61.7% and controls = 73.1% (P = 0.079).In IEM patients, 10/12 (83%) with preop dysphagia had resolution; 11/66 (17%) had new onset dysphagia and 55/66 (83%) never had dysphagia. Comparatively, in non-IEM patients, 22/24 (92%) had dysphagia resolve; 2/24 (8%) had persistent dysphagia; 7/69 (10%) had new onset dysphagia, and 62/69 (90%) never had dysphagia.Overall, 19 (18%) IEM patients were dilated after MSA, whereas 12 (11%) non-IEM patients underwent dilation (P = 0.151). Nine (9%) patients in both groups had their device explanted. Conclusions: Patients with IEM undergoing MSA demonstrate improved quality of life and reduction in acid exposure. Key differences in IEM patients include lower rates of objective GERD resolution, lower resolution of existing dysphagia, higher rates of new onset dysphagia and need for dilation. GERD patients with IEM should be counselled about these possibilities.

Ineffective esophageal motility: The impact of change of criteria in Chicago Classification version 4.0 on predicting outcome after magnetic sphincter augmentation

“…Early tenets of ARS suggested that a diagnosis of IEM should prompt a tailored fundoplication to mitigate postoperative dysphagia. 17 However, in recent years multiple studies have shown similar rates of dysphagia after partial or complete fundoplication in patients with IEM, calling into question the utility of the definition once again. 18,19 The CCv4.0 released in November 2020 included major revisions to the definition of IEM.…”

“…The major concern with IEM and ARS is whether the patient's esophageal body will be able generate enough force to overcome the increased resistance at the EGJ. Early tenets of ARS suggested that a diagnosis of IEM should prompt a tailored fundoplication to mitigate postoperative dysphagia 17 . However, in recent years multiple studies have shown similar rates of dysphagia after partial or complete fundoplication in patients with IEM, calling into question the utility of the definition once again 18,19 .…”

“…A recent study comparing 105 IEM patients undergoing MSA with matched controls had similar results: no significant difference in postoperative GERD-HRQL scores, pH normalization, or device removal rates. 17 These findings highlight that there is tremendous room for IEM definition improvement in the surgical population.…”

“…A recent study of IEM after MSA found similar results, reporting dysphagia in 13/78 (17%) patients with IEM and 9/93 (10%) patients without IEM, a difference that was not significant. 17 These findings suggest that the new definition of IEM has limited utility in the assessment of the antireflux surgical candidate.…”

Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review

“…Dominguez-Profeta et al [89] found that adequate peristaltic reserve using the DCI after multiple rapid swallows correlated with a decreased incidence of dysphagia following MSA implantation. In a multicenter study including 210 patients, 105 with IEM and 105 without IEM, Baison et al [90] found that age > 45 years, preoperative dysphagia, MSA size < 15 beads, and < 40% intact swallows on preoperative manometry were independent risk factors for the need of endoscopic dilation or device removal. All patients requiring removal had a DCI < 200 mm Hg and < 20% intact swallows.…”