We appreciate Dr. Herbella’s thorough review on our article. Indeed, the updated classification on esophageal dysmotility based on high-resolution manometry brings a new perspective for the treatment of patients with gastroesophageal reflux disease (GERD). Due to the high prevalence of GERD, and its commonly related esophageal conditions, is it crucial to understand not only the benefits of surgical treatment for this disease, but also which surgical technique is most appropriate in this scenario. This is particularly important for patients with severe esophageal dysmotility, who often present with dysphagia after fundoplication, requiring additional postoperative dilations and continuous use of anti-reflux medication (1).
In our study, we found partial fundoplication to be a feasible approach for patients (N=54) with diagnosis of GERD and severe dysmotility, with less than 6% requiring dilation postoperatively. At long-term follow-up, a significant improvement of dysphagia was seen in 75% of the population. Additionally, a majority of patients were symptom free and did not need proton pump inhibitors after two years, reflecting a significant improvement in quality of life. Most interestingly, 74% of patients had persistence of their dysmotility seen on esophageal testing at long-term, with 10% presenting with radiographic hiatal hernia postoperatively. Still, all were asymptomatic.
These results support that patients with motility or ineffective esophageal motility, who used to be denied standard anti-reflux surgery therapy, can receive effective treatment with partial fundoplication. A recent study of 123 patients also found that patients presenting with less than 50% of effective esophageal peristalsis benefit from a Toupet fundoplication, reaching near normal levels of quality of life (2).
In spite of the accumulated knowledge, the benefits and pitfalls of offering anti-reflux surgery for patients with severe esophageal dysmotility remain understudied. We agree with Dr. Herbella that future double-blinded, randomized clinical trials, including patients who undergo total and partial fundoplication, as well as medical therapy, are needed to fully understand the cost-benefit and outcomes of GERD treatment in this specific population. Nonetheless, as our data showed, Toupet fundoplication may be an effective solution for this burden.
Funding for this study was provided by the Center for Advanced Surgical Technology at the University of Nebraska Medical Center.
Conflicts of Interest: Dmitry Oleynikov is a shareholder of Virtual Incision Corporation. Priscila Rodrigues Armijo has nothing to disclose.
- Armijo PR, Hennings D, Leon M, et al. Surgical management of gastroesophageal reflux disease in patients with severe esophageal dysmotility. J Gastrointest Surg 2019;23:36-42. [Crossref] [PubMed]
- Fuchs HF, Babic B, Fuchs KH, et al. Do patients with gastroesophageal reflux disease and somatoform tendencies benefit from antireflux surgery? World J Gastroenterol 2019;25:388-97. [Crossref] [PubMed]
Cite this article as: Armijo PR, Oleynikov D. Partial fundoplication may be an effective therapy for gastroesophageal reflux disease for patients with severe esophageal dysmotility. Ann Laparosc Endosc Surg 2019;4:36.