Prefundoplication testing: is manometry needed?

Abstract

A prospective, randomized study was conducted to determine whether preoperative esophageal dysmotility affects clinical outcome of gastroesophageal reflux disease (GERD) after laparoscopic fundoplication and whether esophageal motor function changes postoperatively. Two hundred patients with chronic GERD referred for laparoscopic fundoplication underwent clinical assessment, esophagogastroduodenoscopy, esophageal manometry, and 24-h pH monitoring. Patients were stratified according to presence or absence of esophageal dysmotility (100 in each group) and randomized to either a 360° (Nissen) or a 270° (Toupet) fundoplication. This resulted in 50 patients with normal motility and 50 patients with dysmotility undergoing Nissen fundoplications and Toupet fundoplications, respectively. Esophageal dysmotility was defined as primary peristalsis of ≤40% and/or mean distal esophageal pressure of <40 mm Hg. All preoperative tests were repeated 4 months postoperatively. Pre-operative dysmotility was associated with more severe and medically refractory GERD with lower resting LES pressures than normal motility. Postoperative clinical outcome and reflux recurrence were similar and independent of preoperative motility. Reflux recurred in 14% of normal motility patients (four Toupet, 10 Nissen) and 21% of dysmotility patients (11 Toupet, 10 Nissen). Postoperative dysphagia was unrelated to preoperative esophageal motor function (30 normal motility, 31 dysmotility) but dependent on the type of fundoplication (44 Nissen and 17 Toupet patients developed dysphagia). Esophageal motility changed from pathological to normal in 10% and normal to pathological in 5%, with the remaining 85% unchanged. The authors concluded that esophageal dysmotility reflects more severe disease, does not affect postoperative clinical outcome, is not corrected by fundoplication, and requires no tailoring of the surgical procedure.