Anatomical Factors Contributing to Troublesome Dysphagia After Antireflux Surgery
| dc.contributor.advisor | Kiroff, George | |
| dc.contributor.advisor | Myers, Jennifer | |
| dc.contributor.author | Gan, Siang Wei | |
| dc.contributor.school | School of Medicine | en |
| dc.date.issued | 2021 | |
| dc.description.abstract | Laparoscopic anti-reflux surgery, which involves hiatal repair and fundoplication, is an effective treatment for gastro-oesophageal reflux disease. Hiatal repair refers to closure of the diaphragmatic hiatus with repair of hiatal hernia where present, whereas fundoplication entails wrapping of the fundus of the stomach around the distal oesophagus and securing it within the abdominal cavity. However, some patients develop new-onset or worsening dysphagia post-operatively. The cause of troublesome post-operative dysphagia remains unclear, especially in the setting of an intact fundoplication. In this thesis, I propose that objective measurements of post-fundoplication anatomy hold the key to understanding troublesome dysphagia after fundoplication. My aim is to determine if barium swallow, through objective measurements of post-fundoplication gastro-oesophageal junction anatomy, can be used to identify factors contributing to dysphagia after anti-reflux surgery. A review of anatomical factors previously evaluated or proposed as contributory to dysphagia was performed. Following this, novel objective measurements of select anatomical features on barium swallow studies were devised for the gastro-oesophageal junction in patients after fundoplication. Post-operative structured barium swallow studies with fluoroscopy along with pre- and post-operative dysphagia assessments obtained approximately 6-12 months after fundoplication were utilised. Over two scientific exploratory studies, I first sought to determine the level of inter- and intra-observer reproducibility of these objective measurements, followed by a second study determining if these anatomical features correlated with post-operative dysphagia. In the first study (Chapter 2), there was overall good inter- and high intra-observer reproducibility of objective measurements of gastro-oesophageal junction (GOJ) anatomy after fundoplication. Inter-observer reproducibility, using intra-class coefficient correlations, was good or excellent in 71% of all measurements. High agreement was found for measures of diameter, posterior distal oesophageal angle, displacement of the distal oesophagus anteriorly, and degree of angulation of the GOJ relative to the distal oesophagus, whereas measures of fundal wrap length were more variable. Greater anterior displacement and angulation of the distal oesophagus were subsequently found to be associated with troublesome dysphagia after a complete (360°) wrap of the fundus around the distal oesophagus (Chapter 3), the likely mechanism of which is through increasing oesophageal outflow resistance. After partial anterior (90°) fundoplication, patients with or without troublesome dysphagia had no significant difference in the extent of anterior displacement and angulation of the distal oesophagus. A small reduction in maximal distal oesophageal luminal diameter relative to wrap opening luminal diameter was associated with worsening dysphagia after partial fundoplication. In conclusion, barium swallow studies recorded with fluoroscopy show potential for detecting objective but subtle changes of post-fundoplication anatomy. Anatomical measurements were reproducible, increasing the validity of the measurements for use in further studies. Future studies need to confirm the association between troublesome dysphagia and greater anterior displacement and angulation, to inform a review of technical steps requiring care or modification during fundoplication and hiatal repair to further reduce post-surgical dysphagia. | en |
| dc.description.dissertation | Thesis (MPhil) -- University of Adelaide, Adelaide Medical School, 2020 | en |
| dc.identifier.uri | https://hdl.handle.net/2440/132627 | |
| dc.language.iso | en | en |
| dc.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: http://www.adelaide.edu.au/legals | en |
| dc.subject | dysphagia | en |
| dc.subject | barium swallow | en |
| dc.subject | fundoplication | en |
| dc.subject | antireflux surgery | en |
| dc.subject | reproducibility | en |
| dc.subject | gastro-oesophageal junction | en |
| dc.subject | fluoroscopy | en |
| dc.title | Anatomical Factors Contributing to Troublesome Dysphagia After Antireflux Surgery | en |
| dc.type | Thesis | en |
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