Distensibility index might predict the risk of developing new onset or worsening dysphagia after anti-reflux surgery

Dysphagia is one of the most common complications following anti-reflux surgery (ARS). The factors affecting the development of new onset or worsening dysphagia are not well understood. This study aimed to investigate how lower esophageal sphincter distensibility impacts the development of new onset or worsening dysphagia after ARS.

A review of patients who underwent robotic ARS was conducted. All patients had intra-operative EndoFLIP monitoring at two-time points, pre-repair, and post-wrap. Dysphagia was assessed pre-operatively and at 3-6 months after surgery.

Out of 168 patients (63.8%) with 3- to 6-month follow-up, 24 patients (14.2%) developed new onset or worsening post-operative dysphagia. Among these, 13 patients reported mild symptoms, and 11 patients experienced moderate-to-severe dysphagia. Patients with new onset or worsening post-operative dysphagia had lower DI values compared to those without [0.9 IQR (0.7-1.5) mm²/mmHg vs 1.3 IQR (0.9-1.8) mm²/mmHg, p = 0.04]. No significant differences were observed in post-wrap high pressure zone length (HPZ) between groups [3.5 IQR (3-4) cm vs 3.5 IQR (3-3.8) cm, p = 0.71]. A post-wrap DI value of ( $\le$ 0.9 mm²/mmHg) was associated with increased risk of new onset/worsening dysphagia [4.1 95% CI (1.3-13), p = 0.02].

Patients who developed new onset or worsening dysphagia after ARS had lower post-wrap LES DI values compared to those who did not. A post-wrap DI value of ( $\le$ 0.9 mm²/mmHg) was associated with increased risk of new onset/worsening dysphagia. While clinicians should consider optimizing post-wrap DI values during ARS to reduce the risk of post-operative new onset/worsening dysphagia, larger scale prospective studies are needed to validate the application of this cutoff and determine its role in tailoring fundoplication, given the single-center design and the limited sample size of our cohort.