C0206 - Risk Factors for Dysphagia and Need for Upper Endoscopy in Patients With a Hiatal Hernia Who Undergo Anti-Reflux Surgery

Monday, October 24, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Pedro Cortes, MD

Mayo Clinic
Jacksonville, FL

Pedro Cortés, MD¹, Jennifer Zeng, BA¹, Enrique Elli, MD², Dawn Francis, MD¹, Kenneth DeVault, MD², Maoyin Pang, MD, PhD³
¹Mayo Clinic, Jacksonville, FL; ²Mayo Clinic Jacksonville, Jacksonville, FL; ³Mayo Clinic Florida, Jacksonville, FL

Introduction: Dysphagia is a common adverse event (AE) of anti-reflux surgery, including hiatal hernia repair (HHR) and fundoplication (F). We aimed to determine the frequency, outcomes, and factors associated with the emergence of dysphagia, and need for endoscopy after anti-reflux surgery in patients with hiatal hernia (HH) and gastroesophageal reflux disease (GERD).

Methods: We performed a retrospective study across four academic centers between January 2015 and December 2021 in patients with HH and GERD who underwent anti-reflux surgery, either HHR, F, or HHR+F. Kaplan-Meier Estimates with Cox Proportional Hazards Regression Analysis were utilized to determine features associated with the emergence of dysphagia and need for upper endoscopy (EGD) after anti-reflux surgery in patients with HH. Statistical significance was defined as p< 0.10 given the small sample size. Statistical analysis was performed utilizing BlueSky Statistics software v. 7.0.

Results: A total of 75 patients were included. Table 1. Anti-reflux surgeries included HHR+F (69.3%), HHR (14.7%), or F alone (16.0%). 10.7% of patients had an AE within 30 days. 40.0% developed dysphagia at a median time of 270 days (IQR: 55-907). An EGD was performed in 25 patients (33.3%) with 5 patients having an intervention for dysphagia. Re-do surgery occurred in 10.7% of patients at a median time of 453.0 days (IQR: 349-577). Class II obesity, utilizing mesh for HHR, and using a proton-pump inhibitor prior to surgery were the strongest predictors for developing dysphagia. An HHR+F approached significance for being protective against dysphagia, p=0.1043. Having had a large HH on pre-surgical CT imaging or endoscopic evaluation were strongly associated with the need for EGD after surgery, p=0.0023 and p=0.0263, respectively. Increased blood loss during surgery, younger age, class II obesity, and F alone were also strongly associated with undergoing EGD after surgery at p< 0.05. Figure 1. Dyspepsia (40.0%) was the most common indication for EGD.

Discussion: We found dysphagia occurred in 40.0% of patients undergoing anti-reflux surgery. Class II obesity, type of surgery, and a large HH were the strongest predictors for dysphagia and the need for EGD. These characteristics likely have a synergistic effect to increase the risk of AEs after anti-reflux surgery. Further studies on the long-term outcomes of anti-reflux surgery in the management of patients with hiatal hernia are needed.

Figure: Figure 1: Kaplan-Meier Estimates of A) Time to Initial Discontinuation of PPI after Anti-Reflux Surgery in Patients with Hiatal Hernia, B) Time to Discontinuation of PPI by Pre-Surgery EGD, and C) Time to Restarting of PPI after Anti-Reflux Surgery by Class II Obesity or Higher (>/= 35.0 kg/m2). Legend A: Blue = BMI >/= 35 kg/m2, Red = BMI < 35 kg/m2; Legend B: Blue = Hiatal Hernia Repair + Fundoplication, Red = Hiatal Hernia Repair or Fundoplication, alone; Legend C: Blue = Fundoplication, alone, Red = Hiatal Hernia Repair +/- Fundoplication.

Baseline Characteristics		Unadjusted Cox Proportional Hazards Regression
Median (IQR) or Fraction (%)		Dysphagia After Surgery		EGD Performed After Surgery
	All Patients (N=75)	HR (95% CI)	P value	HR (95% CI)	P value
Age at Surgery, per 10 years	68.7 (59.9-75.2)	0.94 (0.67-1.30)	0.69	0.66 (0.46-0.96)	0.0284
Male	19 (25.3%)	0.77 (0.31-1.89)	0.57	0.84 (0.33-2.14)	0.71
White race	75 (100%)	NA	NA	NA	NA
Hispanic ethnicity	1 (1.3%)	NA	NA	NA	NA
Height, per 30 cm	164.0 (158.3-172.8)	1.26 (0.43-3.72)	0.68	1.16 (0.37-3.68)	0.80
Weight, per 10 kg	83.9 (70.7-92.9)	0.94 (0.75-1.17)	0.57	0.96 (0.73-1.25)	0.96
Body Mass Index, per 5 kg/m²	30.8 (27.2-33.6)	1.14 (0.99-1.33)	0.0752	1.22 (1.05-1.41)	0.0113
· Body Mass Index ≥ 35 kg/m²	14 (18.7%)	2.60 (1.18-5.72)	0.0172	1.78 (0.73-4.30)	0.20
Obesity	42 (56.0%)	0.78 (0.38-1.61)	0.51	0.98 (0.44-2.17)	0.96
Never Smoker	43 (57.3%)	1.45 (0.69-3.06)	0.33	1.30 (0.58-2.91)	0.53
Moderate to Severe Alcohol Use	16 (21.3%)	0.69 (0.26-1.80)	0.45	1.13 (0.42-3.02)	0.81
Type 2 Diabetes	16 (21.3%)	0.94 (0.40-2.20)	0.88	0.95 (0.37-2.43)	0.95
Interstitial Lung Disease	13 (17.3%)	0.65 (0.23-1.88)	0.43	0.81 (0.29-2.21)	0.68
History of Aspiration	4 (5.3%)	0.56 (0.08-4.10)	0.57	0.66 (0.09-4.91)	0.68
Type of Surgery
Hiatal Hernia Repair, alone	11 (14.7%)	1.87 (0.76-4.60)	0.17	0.71 (0.21-2.39)	0.58
· Mesh Utilized	17/63 (22.7%)	2.00 (0.89-4.53)	0.0953	1.08 (0.38-3.07)	0.89
Fundoplication, alone	12 (16.0%)	1.44 (0.58)	3.58)	2.78 (1.14-6.77)	0.0241
· Nissen	53/64 (70.7%)	0.58 (0.21-1.57)	0.28	1.04 (0.30-3.56)	0.95
· Toupet	9/64 (12.0%)	1.67 (0.56-4.95)	0.36	0.70 (0.16-3.02)	0.63
Hiatal Hernia Repair and Fundoplication	52 (69.3%)	0.38 (0.26-1.13)	0.1043	0.60 (0.27-1.34)	0.21
Laparoscopic Approach	71 (94.7%)	0.71 (0.17-2.99)	0.64	1.29 (0.17-9.68)	0.80
Estimated Blood Loss, per 20 mL	20 (10-30)	1.09 (0.97-1.21)	0.14	1.16 (1.02-1.32)	0.0211
Elapsed Time for Surgery, per 30 minutes	142.5 (110.8-174.8)	1.06 (0.78-1.45)	0.70	1.10 (0.75-1.60)	0.62
· Time ≥ 180 minutes	11/36 (14.7%)	0.44 (0.09-2.08)	0.30	0.66 (0.17-2.52)	0.54
Pre-Surgical Evaluation
EGD prior to surgery	55 (73.3%)	1.12 (0.50-2.51)	0.79	0.96 (0.40-2.31)	0.92
· Esophagitis	12/55 (16.0%)	1.53 (0.62-3.76)	0.35	1.34 (0.47-3.76)	0.58
Manometry Performed	32 (42.7%)	0.89 (0.43-1.83)	0.75	0.67 (0.30-1.51)	0.33
· Normal Findings	10 (37.0%)	0.66 (0.17-2.55)	0.54	1.67 (0.36-7.77)	0.52
pH Testing Performed	20 (26.7%)	1.21 (0.55-2.66)	0.63	1.34 (0.58-3.13)	0.54
· Total Acid Exposure, per 3 %	9.8 (6.0-14.3)	0.96 (0.71-1.29)	0.77	0.75 (0.50-1.13)	0.16
· DeMeester Score, per 5 points	32.0 (21.4-51.9)	0.96 (0.83-1.11)	0.59	0.91 (0.76-1.10)	0.33
Large Hiatal Hernia on Endoscopy	28/49 (37.3%)	0.56 (0.24-1.34)	0.19	0.30 (0.11-0.87)	0.0262
Large Hiatal Hernia on CT Imaging	34 (45.3%)	0.61 (0.28-1.30)	0.20	0.19 (0.06-0.55)	0.0023
PPI prior to surgery	62 (82.7%)	3.70 (0.88-15.60)	0.0742	6.24 (0.84-46.3)	0.58
Endpoints
Adverse Events within 30 days	8 (10.7%)	NA	NA	NA	NA
· Median Time to Adverse Event, days	21.5 (9.8-25.8)	NA	NA	NA	NA
Re-do Surgery Performed	8 (10.7%)	NA	NA	NA	NA
· Median Time to Re-do Surgery, days	453.0 (348.5-577.0)	NA	NA	NA	NA
EGD Performed after Surgery	25 (33.3%)	NA	NA	NA	NA
· Median Time to EGD, days	654.0 (189.0-1244.0)	NA	NA	NA	NA
Indications for EGD		NA	NA	NA	NA
· Dysphagia	9 (36.0%)	NA	NA	NA	NA
· Abdominal Pain	3 (12.0%)	NA	NA	NA	NA
· Gastrointestinal Bleed	1 (4.0%)	NA	NA	NA	NA
· Dyspepsia	12 (48.0%)	NA	NA	NA	NA
Occurrence of Dysphagia after Surgery	30 (40.0%)	NA	NA	NA	NA
· Median Time to Dysphagia, days	270.0 (55.0-906.8)	NA	NA	NA	NA
· Median Time to EGD for Dysphagia, days	563.5 (160.8-1228.8)	NA	NA	NA	NA
Intervention Performed for Dysphagia	5/6 (83.3%)	NA	NA	NA	NA
· Balloon dilation	4 (66.7%)	NA	NA	NA	NA
· Esophageal stent	1 (16.7%)	NA	NA	NA	NA

Table: Table 1: Baseline Characteristics of All Patients and Cox Proportional Hazards Regression for Emergence of Dysphagia and Performance of Upper Endoscopy in Patients with a Hiatal Hernia after Anti-Reflux Surgery

Disclosures:

Pedro Cortés indicated no relevant financial relationships.

Jennifer Zeng indicated no relevant financial relationships.

Enrique Elli indicated no relevant financial relationships.

Dawn Francis indicated no relevant financial relationships.

Kenneth DeVault indicated no relevant financial relationships.

Maoyin Pang indicated no relevant financial relationships.

Pedro Cortés, MD¹, Jennifer Zeng, BA¹, Enrique Elli, MD², Dawn Francis, MD¹, Kenneth DeVault, MD², Maoyin Pang, MD, PhD³. C0206 - Risk Factors for Dysphagia and Need for Upper Endoscopy in Patients With a Hiatal Hernia Who Undergo Anti-Reflux Surgery, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.