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Type: Theses
Title: Risk and pathogenesis of dysphagia related to antireflux surgery
Author: Myers, Jennifer C.
Issue Date: 2016
School/Discipline: School of Medicine
Abstract: Dysphagia, the difficulty of swallowing food or drink, is experienced by some patients with gastro-oesophageal reflux disease and is a common adverse effect of antireflux surgery, a procedure involving diaphragmatic hiatal repair and fundoplication. Dysphagia after surgery in the absence of recognisable anatomical abnormalities is poorly understood and thus difficult to treat. Despite modifications to surgical techniques, post-operative dysphagia remains unpredictable (Chapter 1). My aim is to identify patients at risk and the causes of dysphagia related to antireflux surgery. A fundamental premise of this thesis is that objective measurements hold the key to understanding post-fundoplication dysphagia. Five prospective studies are presented which evaluate oesophageal body or oesophago-gastric junction (OGJ) function with regards to: early new-onset and late persistent post-operative dysphagia. Objective data were gathered using: i) luminal manometry alone; ii) impedance combined with manometry, to assess relationships between oesophageal pressure and bolus flow; and iii) three-dimensional pressure recordings of expiratory and inspiratory radial OGJ pressure to assess the contribution of hiatal repair and fundoplication to post-operative dysphagia. These studies show: an ‘oesophageal ileus’ in the early post-operative period, with global failure of primary peristalsis in 70% of patients after total fundoplication, compared with 20% of patients after cholecystectomy. Oesophageal ileus is transient with subsequent return of preoperative motility patterns (Chapter 2). Of all patients undergoing laparoscopic antireflux surgery in the Unit (tertiary care hospital), the incidence of late revisional surgery is low at 5.6%, including 3% for persistent dysphagia. Dysphagia is the most common indication for revisional surgery, albeit with lower patient satisfaction with outcome than revisional surgery for recurrent reflux (Chapter 3). In addition, flawed interaction between oesophageal and OGJ function is implicated in dysphagia. OGJ resistance to outflow is associated with dysphagia when there is sub-optimal distal oesophageal contractile strength and relatively high OGJ relaxation pressure on swallowing (Chapter 4). Limited tools for impedance-manometry data analysis inspired the conceptualisation and development of new automated combined pressure-flow analysis, achieved through scientific collaboration. This novel approach revealed for the first time that some patients have a pre-existing, asymptomatic, subtle variation of viscous bolus compression and movement in relation to oesophageal peristalsis that increases the risk of new-onset postoperative dysphagia (Chapter 5). Fundoplication and hiatal repair alter OGJ anatomy to prevent reflux. However, after surgery, aberrant asymmetry of radial OGJ pressure during inspiration is associated with persistent dysphagia, consistent with a focally restrictive diaphragmatic hiatus from crural repair (Chapter 6). In conclusion, oesophageal ileus in the early post-operative period is transient and the rate of late revisional surgery for troublesome dysphagia is low. Post-surgical dysphagia is related to a pre-existing pattern of sub-optimal bolus transport; and after surgery, inadequate modulation of oesophageal function in response to altered OGJ function. When antireflux surgery results in abnormally skewed OGJ pressures, dysphagia may be due to a ‘snug’ hiatal repair. Future studies hold promise for a reduction in post-surgical dysphagia through examination of local intrinsic modulation of swallowing function and development of objective calibration of hiatal repair.
Advisor: Jamieson, Glyn Garfield
Dent, John
Watson, David
Dissertation Note: Thesis (Ph.D.) (Research by Publication) -- University of Adelaide, School of Medicine, 2016.
Keywords: dysphagia
reflux disease
laparoscopic fundoplication
Research by Publication
Provenance: This electronic version is made publicly available by the University of Adelaide in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. This thesis may incorporate third party material which has been used by the author pursuant to Fair Dealing exceptions. If you are the owner of any included third party copyright material you wish to be removed from this electronic version, please complete the take down form located at:
DOI: 10.4225/55/5912b05a84aac
Appears in Collections:Research Theses

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