Is that ‘floppy’ fundoplication tight enough?

Laparoscopic fundoplication is the treatment of choice for medically refractory gastroesophageal reflux disease (GERD). Surgeons seek to create a competent valve at the gastroesophageal junction (GEJ) but are careful to construct a ‘floppy’ fundoplication that is not too tight to minimize side effects. The endoscopic functional luminal-imaging probe (EndoFLIP®) uses impedance planimetry to assess the GEJ intraoperatively. We sought to determine if EndoFLIP variables are associated with symptomatic outcomes following fundoplication. We conducted a retrospective review of prospectively maintained data on subjects who underwent primary laparoscopic fundoplication at a single institution between 2014 and 2018. All patients met standard indications for antireflux surgery. Minimum diameter (Dmin), cross-sectional area (CSA), intra-bag pressure, and distensibility index of the GEJ were obtained at 30 mL volumes. GERD Health Related Quality of Life (GERD-HRQL) surveys were administered pre- and postoperatively. Patients were excluded if they underwent fundoplication without EndoFLIP assessment or if they did not complete a postop GERD-HRQL survey. Receiver operating characteristic curves were used to determine if EndoFLIP measurements were correlated with symptomatic outcomes. Forty-three patients met inclusion criteria. The change in Dmin and CSA measures during fundoplication were associated with daily or more frequent heartburn at 6 or more months postop. A decrease in Dmin of 0.15 mm or less (AUC = 0.718, sensitivity: 71%, specificity: 69%) and a decrease in CSA of 1.5 mm2 or less (AUC = 0.728, sensitivity: 71%, specificity: 70%) were associated with severe heartburn. GEJ opening dynamics attained by EndoFLIP appear to be associated with symptomatic outcomes. When the Dmin and CSA do not decrease by a defined threshold, heartburn is more likely to be severe at 6 or more months postoperatively. This suggests that the fundoplication may not be tight enough to prevent persistent or recurrent GERD.