Ambulatory pH-metry Research Articles

Early and intermediate term outcomes after laparoscopic one-anastomosis gastric bypass for morbidly obese patients: a single center experience.

To evaluate our outcomes of laparoscopic one-anastomosis gastric bypass (LOAGB) as a primary weight loss procedure. We evaluated the impact of biliary reflux by combination of upper endoscopy (UGIE), ambulatory pH metry, and ambulatory biliary reflux monitoring. We reviewed the data of patients who underwent LOAGB during the period between July 2015 till August 2018. Forty consecutive patients were included in the study. Thirty-seven patients (92.5%) had obesity related comorbidities. The median follow-up duration was 18 months (6-36 months). The 1-, 2-, and 3-years excess weight loss percentages were 53.1%, 60.4%, and 62.3%. At three years follow-up, complete remission of diabetes mellitus occurred in 7/7 patients (100%) and of hypertension in 4/7 patients (57.1%). Eighteen patients (45%) accepted to undergo UGIE with routine biopsies and evaluation of acidic and biliary reflux. All examined patients had negative acid reflux results according to ambulatory PH metry with median DeMeester score of 2 (0.3-8.7). According to ambulatory biliary reflux monitoring, 17/18 patients (94.1%) had posi- tive result. Only 6/18 patients (33.3%) had symptoms of biliary reflux and had positive symptom index on bilimetric study. Regarding UGIE, all patients had just gastritis and reflux esophagitis with no evidence of gross mucosal changes. Pathological examination of all routine biopsies did not show any sign of faveolar hyperplasia, atypia or malignancy. LOAGB is a safe and efficient bariatric procedure with acceptable morbidity rate. LOAGB is not associated with significant biliary reflux or pathological changes in the esophagogastric mucosa.

Esophageal Function Tests are Not Associated with Barium Swallow Findings in Advanced Lung Disease.

Gastroesophageal reflux disease and esophageal dysmotility are common in patients with advanced lung disease (ALD) and are associated with worse outcomes. Assessing esophageal function in these patients is relevant for determining pulmonary transplant eligibility and prognosticating post-transplant outcomes. Barium Swallow (BaS) is a non-invasive testing modality often performed as a complement to formal esophageal function tests (EFTs), but its role and clinical utility in this context is unknown. Therefore, we aimed to determine the relationship between BaS and EFTs with high-resolution manometry (HRM) and 24-h ambulatory pH-metry in patients with ALD. We performed a retrospective study of 226 consecutive patients undergoing evaluation for lung transplantation at a single center. All patients underwent EFTs and BaS independent of clinical history or symptoms per institutional protocol. Appropriate statistical tests were performed to evaluate the relationship between EFTs and BaS. Mucosal, reflux and motility findings were categorized. Abnormal motility was reported in 133 (59%) patients by BaS and 99 (44%) by HRM, with a significant difference in the proportions of patients with abnormal studies (p < 0.01). There were 7 (26%) patients with abnormal barium tablet passage who had normal HRM. The sensitivity (35%) and specificity (77%) for detecting pathologic reflux with BaS was poor. Inducibility of reflux and barium column height were not associated with pH-metry results. No clinically significant luminal irregularities were identified. In conclusion, while BaS can non-invasively assess esophageal mucosa, its findings are not associated with EFTs in patients with ALD.

Evolution of gastroesophageal reflux after laparoscopic vertical gastrectomy. A radiographic, manometric and pH-metric study.

the relationship between laparoscopic vertical gastrectomy (LVG) and gastroesophageal reflux (GER) is still controversial. Therefore, its study is of great interest in order to obtain definitive conclusions. The goal of the study was to establish whether LVG modifies pH-metric GER in obese patients and to analyze the associated factors. the first 26 patients who underwent LVG in our institution were enrolled in the study. A barium swallow, 24-hour ambulatory pH-metry and four-channel intraluminal esophageal manometry (IEM) were all performed before and one year after surgery. among the pH-metric data, there was a significant increase in the DeMeester index after the procedure (p = 0.028), while other parameters remained unchanged. Furthermore, 50% of patients with preoperative pH-metric GER had normal values at one year after surgery. IEM showed a decrease in lower esophageal sphincter (LES) pressure and in the mean wave amplitude at the distal third of the esophagus (p = 0.007 and p = 0.025, respectively). The rate of newly-developed hiatal hernias in the radiographic study was 36.4%. LVG mildly increases GER, which is likely related to the development of hiatal hernias and a decrease in LES pressure and esophageal sweep. However, LVG should not be contraindicated for patients with preoperative pH-metric GER, as this may clear after the procedure.

Use of Esophageal pH Monitoring to Minimize Proton-Pump Inhibitor Utilization in Patients with Gastroesophageal Reflux Symptoms.

Due to concerns about long-term PPI use in patients with acid reflux, we aimed at minimizing PPI use, either by avoiding initiating therapy, downscaling to other therapies, or introducing endoscopic or surgical options. To examine the role of esophageal ambulatory pHmetry in minimizing PPI use in patients with heartburn and acid regurgitation. Retrospective cohort analysis of patients with reflux symptoms, who underwent endoscopy, manometry, and ambulatory pHmetry to define the need for PPI. Patients were classified as: (1) never users; (2) partial responders to PPI; (3) users with complete response to PPI. Patients were then managed as: (1) PPI non-users; (2) PPI-initiated, and (3) PPI-continued. Of 286 patients with heartburn and regurgitation, 103 (36%) were found to have normal and 183 (64%) abnormal esophageal acid exposure (AET). In the normal AET group, 44/103 had not been treated and were not initiated on PPI. Of the 59 who had previously received PPI, 52 stopped and 7 continued PPI. Hence, PPI were avoided in 96/103 patients (93%). In the abnormal AET group, 61/183 had not been treated and 38 were initiated on PPI and 23 on other therapies. In the 122 patients previously treated with PPI, 24 were not treated with PPI, but with H2RAs, prokinetics, endoscopic, or surgical therapy. Hence, PPI therapy was avoided in 47/183 patients (26%). In patients with GER symptoms, esophageal pHmetry may avert PPI use in 50%. In the era of caution regarding PPIs, early testing may provide assurance and justification.

Mo1503 - Gastroesophageal Reflux Disease Symptom Correlation with Ambulatory PH-Metry and Esophageal High Resolution Manometry in Lung Transplant Candidates

Mo1503 - Gastroesophageal Reflux Disease Symptom Correlation with Ambulatory PH-Metry and Esophageal High Resolution Manometry in Lung Transplant Candidates

Lower esophageal sphincter pressures in gastroesophageal reflux disease: Where do they stand?

Background: Esophageal manometry is mandatory for localization of lower esophageal sphincter (LES) in patients undergoing ambulatory esophageal pH-metry for proper positioning of the pH-sensing catheter. Manometry not only gives the location of LES but also provides its tone in terms of basal lower esophageal sphincter pressure (BLESP) in mm Hg. Aims and Objectives: To study the LES pressures in cases of gastroesophageal reflux disease and to evaluate its significance by determining correlation between LES pressures and DeMeester score. Materials and Methods: In the study, 54 subjects with clinical diagnosis of gastroesophageal reflux participated. Manometry was performed using pneumohydraulic water perfused system, followed by a 24-h ambulatory esophageal pH-metry. The data were subjected to statistical analysis using SPSS software, version 22. Results: The mean BLESP was 13.68 ± 3.93 mm Hg, and DeMeester score was 16.94 ± 9.57. A significant negative correlation with a Pearson’s correlation coefficient (r) of -0.632 (p < 0.001) was seen between BLESP and DeMeester score. Conclusion: High DeMeester score as in cases of gastroesophageal reflux is found to be significantly negatively correlated with low values of BLESP.

Is internal anal sphincter degeneration associated with lower oesophageal sphincter dysfunction?

IntroductionInternal anal sphincter (IAS) degeneration is the cause of up to 13% of faecal incontinence referrals to a tertiary centre. The authors speculated that IAS degeneration may represent one aspect...

24-hour dual-probe ambulatory pH-metry findings in cases of laryngopharyngeal reflux disease

Background: Laryngopharyngeal reflux disease (LPRD) cases are common in clinical practice and usually neglected for want of a definitive diagnosis. Diagnosis requires a documented evidence of fall in pH levels in the laryngopharynx with dual-probe 24-hour ambulatory pH-metry. Aim: To study pH-metry findings in laryngopharyngeal reflux cases. Settings and Design: Study was done in a tertiary teaching hospital. Material and Methods: A total of 30 normal volunteers (Group A) and 65 patients (Group B) with complaints of hoarseness of voice for more than six weeks in the age group of 20 to 40 years were studied. A thorough ENT examination including fiberoptic laryngoscopy (FOL) was done on all cases. Group B was further divided into two subgroups. Subgroup B1 (n = 32) consisted of FOL positive and subgroup B2 (n = 33) comprised of FOL negative patients by reflux finding score. 24-hour ambulatory pH-metry was done for both groups. Results: Group A had no abnormal reflux patterns. In Subgroup B1, all 32 patients showed at least single laryngopharyngeal reflux episode over the 24-hour period. The most common pattern was 2 to 5 episodes occurring in 16/32 cases. Of the 32, five (15.6%) also had abnormal De Meester's score (gastroesophageal reflux disease [GERD] positive). In subgroup B2, 2 of 33 patients showed a typical LPR on 24-hour ambulatory pH-metry, despite showing LPRD negativity on FOL. None had an abnormal De Meester's score. Conclusion: LPRD may not coexist with GERD. Two to five reflux episodes pattern were found to be more common in LPR patients. Dual-sensor pH-metry is confirmatory for establishing diagnosis of LPRD.

24-h pH-metry and Multichannel Intraluminal Impedance Monitoring in Obese Patients with and without Gastroesophageal Reflux Disease Symptoms

The 24-h ambulatory pH-metry with multichannel intraluminal impedance monitoring (24-h pH-metry+MII) allows the simultaneous assessment of chemical and physical properties of esophageal refluxes and the detection of its proximal migration. Gastroesophageal reflux (GER) was investigated in obese symptomatic (obese gastroesophageal reflux disease, GERD) and asymptomatic (obese non-GERD) patients. The data were compared with those obtained from non-obese GERD patients and a control group. Thirty-five (20 non-GERD, 15 GERD) obese patients and 15 non-obese GERD were investigated with 24-h pH-metry+MII. Ten normal weight subjects with normal 24-h pH-metry+MII were used as control group. The percent time acid exposure was significantly higher in obese non-GERD than controls (p = 0.007). Acid reflux episodes were increased vs. controls in obese non-GERD (p = 0.005) and obese GERD (p = 0.034). Upright position showed a significant increase of reflux episodes in non-obese GERD (p = 0.034) and in obese non-GERD (p = 0.027) vs. controls. Recumbent position showed reflux episodes significantly increased vs. controls in obese non-GERD (p = 0.002), obese GERD (p = 0.021), and non-obese GERD (p = 0.033). In obese non-GERD, waist circumference (WC) correlated negatively with upright position episodes (r = -0.53; p = 0.043) and with proximal migration episodes, i.e., total (r = -0.60; p = 0.018), acid (r = -0.55; p = 0.033), and weakly acidic refluxes (r = -0.56; p = 0.031). Obese patients showed an increased number of refluxes with acid content. Refluxes with proximal extent were significantly higher in obese non-GERD than in controls and non-obese GERD patients. No difference was observed between the two obese patient groups. In asymptomatic obese patients, the WC correlated with proximal extent episodes.

An objective study of acid reflux and cough in children using an ambulatory pHmetry–cough logger

ObjectiveThere are no objective ambulatory studies on the temporal relationship between reflux and cough in children. Commercial pHmetry loggers have slow capture rates (0.25 Hz) that limit objective quantification of...

GERD-related Chronic Cough

GERD-related Chronic Cough

Utility of esophageal manometry and pH-metry in gastroesophageal reflux disease before surgery

The necessity of manometric evaluation before fundoplication in patients with gastroesophageal reflux disease is still a matter of debate. However, misdiagnosis can be responsible for postoperative problems. We aimed to evaluate the necessities of manometry and pH-metry before fundoplication in order to prevent possible complications after surgery. Between 1997 and 2004, 259 consecutive patients who referred to our laboratory with a diagnosis of gastroesophageal reflux disease and request for manometric test before surgery were evaluated retrospectively. Manometric analysis was performed in all patients and 24-hour ambulatory pH-metry in 91 of them. The mean age of the patients was 42.6+/-13 years and 51% were female. While 102 (39.4%) of the patients had normal esophageal motility, 122 (47.1%) had gastroesophageal reflux-related dysmotility (22% with ineffective esophageal motility, 25.1% with hypotensive lower esophageal sphincter). Primary esophageal motility disorders were detected in 29 (11.2%) patients (4 achalasia, 24 uncoordinated contractions and 1 nutcracker esophagus). Six patients had secondary dysmotility caused by scleroderma. Pathologic reflux was detected in 54 (59.3%) patients in whom pH-metry was performed. Our results support that manometry and pH-metry must be performed before surgery in gastroesophageal reflux disease.

Dysfunction of the lower esophageal sphincter and dysmotility of the tubular esophagus in morbidly obese patients

Morbid obesity is associated with gastroesophageal reflux (GERD). The aim of this prospective study was to determine esophageal motility in asymptomatic morbidly obese patients and compare it to non-obese individuals. Forty-seven morbidly obese patients without GERD symptoms and 15 normal weight individuals were divided into four groups according to their body mass index (BMI; group I, <30 kg/m2; group II, 35-39.9 kg/m2; group III, 40-49.9 kg/m2; group IV, >or=50 kg/m2). Standard stationary water-perfused manometry was performed for the assessment of anatomy and function of the lower esophageal sphincter (LES). Twenty-four-hour ambulatory pH-metry and measurement of esophageal motility were performed with a microtransducer sleeve catheter. Data are given as mean+/-SD, and the results of groups II-IV were compared to the non-obese individuals from group I. Patients with morbid obesity had significantly lower LES pressures than non-obese individuals (I, 15.1+/-4.9; II-IV, 10.5+/-5.4, mmHg, p<0.05 vs. I) and showed an altered esophageal motility with respect to contraction frequency (I, 1.8+/-0.7/min; II-IV, 3.6+/-2.5/min; p<0.05 vs. I) and contraction amplitude (I, 38+/-12 mmHg; II-IV, 33+/-17 mmHg; p<0.05 vs. I). Furthermore, these patients had significantly higher DeMeester scores than non-obese individuals. Length and relaxation of the LES as well as propulsion velocity of the tubular esophagus did not differ. Patients with morbid obesity (=BMI>40 kg/m2) have a dysfunction of the LES and an altered esophageal motility, even when they are asymptomatic for GERD symptoms.

Influence of Esophageal pH Recording on Physical Activity in Children

Twenty-four-hour pH-metry represents the gold standard for the diagnosis of gastroesophageal reflux. Ambulatory esophageal pH recording provides a better reflection of occurrences under normal domestic living conditions, but it may influence physical activity. The aim of this study was to assess the influence of ambulatory esophageal pH recording on physical activity in children. This prospective study included 22 patients (18 boys, 4 girls) 3 to 15 years old (mean age 6.9 +/- 2.3 years) who had been referred for ambulatory pH-metry. The 24-hour physical activity was measured twice in each child using a triaxial accelerometer 1 week before or after pH-metry and during pH-metry. Levels of intensity of physical activity (low: sedentary activities; moderate: walking; high: intense activities such as jumping, running, and sport) were compared by the paired nonparametric Wilcoxon test. Physical activity was 53% lower during 24-hour pH-metry than when it was not present (P < 0.0005). The duration of low-level physical activity was longer during pH-metry (84% vs 73%; P < 0.01). The duration of moderate-intensity and high-intensity physical activity was shorter during pH-metry (16% vs 24% and 0.2% vs 2.2%, respectively; P < 0.005 and P < 0.0001). Ambulatory 24-hour esophageal pH recording substantially decreases physical activity, mainly high-level physical activity. Whether such changes in activity decrease the sensitivity of pH-metry and lead to false negative results in some children remains to be assessed.

Single‐session, graded esophageal dilation without fluoroscopy in outpatients with lower esophageal (Schatzki’s) rings: A prospective, long‐term follow‐up study

Distal esophageal (Schatzki's) ring is a frequent cause of dysphagia. Bougienage is generally effective but relapses are common. The aim of this study was to evaluate the safety and long-term efficacy of single-session graded esophageal dilation with Savary dilators, without fluoroscopic guidance, in outpatients who presented with Schatzki's ring. The study was performed on 44 consecutive patients with symptomatic Schatzki's ring, detected endoscopically and/or radiologically. Graded esophageal dilation was performed as an outpatient procedure in a single session with Savary dilators, without fluoroscopic guidance. After appropriate assessment with esophageal manometry and 24 h ambulatory pHmetry, patients with documented gastroesophageal reflux disease (GERD) were treated with omeprazole continuously. All results, including clinical follow up and technical aspects of bougienage, were recorded prospectively. The necessity for re-dilation after documentation of the ring with endoscopy and/or radiology was considered as a relapse of the ring. In four (9%) patients a second session was necessary to ensure complete symptom relief. Two (4.5%) patients developed post-dilation bacteremia and were managed with antibiotics as outpatients. Patients with (n = 14) or without (n = 30) GERD were comparable with respect to sex, age, body mass index, smoke and ethanol consumption, diameter of the esophageal lumen at the level of the ring, resting lower esophageal sphincter pressure, duration of dysphagia, need for taking antacids during the follow-up period, and duration of follow-up. There was no recurrence of the ring in patients with GERD during a mean follow-up period of 43.8 +/- 9.3 months (range 27-62 months); however, in patients without GERD, during a mean follow-up period of 40.6 +/- 12.2 months (range 10-58 months), 32% of patients relapsed after a mean 19.9 +/- 10.6 months (P = 0.04). Single-session graded esophageal dilation with large caliber Savary dilators without fluoroscopic guidance can be safely used for the symptomatic relief in patients with lower esophageal (Schatzki's) rings. GERD should be treated if present in order to prevent a symptomatic recurrence of the ring.

Airway Manifestations of Pediatric Eosinophilic Esophagitis: A Clinical and Histopathologic Report of an Emerging Association

Pediatric eosinophilic esophagitis (EE) typically presents with dysphagia, vomiting, dyspepsia, or food impaction. The purpose of this study was to highlight the emerging association of pediatric EE and airway disease. An additional goal of this study was to describe the unique histopathologic findings found in EE and specifically explore the potential role of the cytotoxic protein called eosinophil major basic protein (MBP) in the pathophysiology of the disease. A retrospective review of 3 children with EE and airway symptoms included symptom presentation, aerodigestive tract endoscopic findings, ambulatory 24-hour dual pH-metry, allergy tests, treatment modalities, and treatment response. Esophageal tissue obtained from biopsies of each patient was evaluated by hematoxylin and eosin to determine the number of eosinophils per high-power field, by immunofluorescent anti-MBP staining to determine the presence of MBP, and by standard light and transmission electron microscopy to evaluate eosinophil migration patterns. All patients had airway inflammation that included nonspecific laryngeal edema and grade I or II subglottic stenosis. Allergy testing was positive in the 2 patients who were tested. All patients had symptoms refractory to standard reflux therapy. Ambulatory pH-metry findings were normal in 2 patients and abnormal in 1 patient despite maximum treatment. Two patients had visual abnormalities seen during esophageal examination. The number of eosinophils ranged from 20 to 45 per high-power field. Intracellular and extracellular MBP deposition was found in all esophageal biopsy specimens. All patients were treated with swallowed fluticasone, and 2 had symptom relapses that required repeat treatment. The spectrum of pediatric EE can include upper airway disease. Intracellular and extracellular MBP deposition is present in EE, which potentially releases cytotoxic mediators that explain the esophageal and airway clinical symptoms seen in those with the disease. Eosinophilic esophagitis should be considered in patients with a history of atopic diseases and unexplained upper airway findings refractory to reflux treatment. Treatment with swallowed fluticasone is successful; however, relapses are common and require repeat treatment and close follow-up.

Analysis of the acidity index and integrated intragastric acidity in 645 patients presenting with gastroesophageal reflux disease symptoms

Objective. In a recent study of patients receiving proton-pump inhibitor (PPI) therapy, a new parameter, the acidity index, was described as being less complicated to calculate and of comparable accuracy (r=0.93) to integrated intragastric acidity (IA) in assessing intragastric pH control. The aim of this study was to correlate AI with IA using a large database of ambulatory 24-h pH-metry studies in untreated patients presenting with gastroesophageal reflux disease (GERD) symptoms. Material and methods. We retrospectively analyzed 645 studies obtained from 1995 to 2001. Daytime (0800 h–2200 h), night-time (2200 h–0800 h) and 24-h IA and AI were calculated according to age, gender and the presence or absence of GERD, and correlations between these parameters were assessed using linear regression with F-statistic values, p-values and Akaike's Information Criterion values. GERD was defined as total esophageal pH time <4.0, 5 cm above the lower esophageal sphincter, for ≥4.2% of the day. IA and AI were calculated as follows: IA (mmol.h/l) = ∑(acid in mmol/l at time “t” + acid in mmol/l at time “t − 1”)/2×(“t”–“t − 1”); AI=(%time pH < 4–%time pH < 3)×1+(%time pH < 3–%time pH < 2)×10+(%time pH < 2–%time pH < 1)×100+(%time pH < 1–%time pH < 0.8)×1000. Results. Overall, the mean 24-h IA value was 882.0±820.0 mmol.h/l (daytime 392.0±400.0, night-time 490.0±486.0). The mean 24-h AI value was 102.0±87.0 (daytime 86.0±80.0, night-time 120.0±114.0, p<0.001). The mean 24-h IA value was 1057.0±829.4 mmol.h/l (daytime 459.8±406.0, night-time 597.2±500.4, p<0.001) in GERD patients and 713.0±775.0 mmol.h/l (daytime 326.0±383.0, night-time 387.0±448.5) in non-GERD patients (p<0.001). The mean 24-h AI value was 122.1±88.1 (daytime 101.4±82.5, night-time 145.3±120.7) in GERD patients and 83.0±81.0 (daytime 71.0±73.9, night-time 96.4±102.6) in non-GERD patients (p<0.001). Our statistical modeling demonstrated that the correlation between the acidity index and IA becomes progressively poorer with increasing values of acidity. Conclusions. We conclude that gastric acid production assessed by both IA and AI is higher during evening hours in comparison with daytime hours and the difference between night-time and daytime values is statistically significant. In addition, gastric acid production assessed by both IA and AI is significantly higher in GERD patients than non-GERD patients. This difference is primarily due to differences in nocturnal acid production. The AI correlates poorly with measured IA, especially at higher levels of gastric acidity. Therefore, AI is not an acceptable surrogate for IA in assessing gastric acid production.

Laparoscopic vs open approach for Nissen fundoplication

Several studies, most of them nonrandomized, have shown similar functional results for both laparoscopic and open Nissen fundoplication, the operation of choice for the treatment of gastroesophageal reflux disease (GERD). A total of 106 patients with documented GERD were randomized to receive either a laparoscopic or an open Nissen fundoplication. Preoperative and postoperative investigations included clinical assessment, esophagogram, upper gastrointestinal endoscopy, esophageal manometry, and 24-h ambulatory pHmetry. Both approaches were successful in controlling reflux. There was an overall improvement in esophageal peristalsis and an increase in lower esophageal sphincter (LES) pressure in both groups. Open Nissen fundoplication was associated with a significantly increased rate of wound (p <0.001) and respiratory (p <0.05) complications. Hospitalization was also longer after the open technique (p <0.001). At 3-month follow-up, although the rate of postoperative dysphagia was similar for the two approaches, the open approach was associated with a significantly higher incidence of postprandial epigastric fullness (p <0.05) and bloating syndrome (p <0.01). The open and laparoscopic approaches for the Nissen fundoplication are equally effective in controlling GERD. The open approach is associated with a significantly higher rate of wound and respiratory complications and, at early stages, an increased rate of postprandial epigastric fullness and abdominal bloating. The dysphagia rate is similar with both methods.

Esophageal motor dysfunction persists in children after surgical cure of reflux: An ambulatory manometric study

Background/Purpose: Esophageal dysmotility shown by perfusion manometry in children with gastroesophageal reflux can be primary or acquired. This study examines by combined ambulatory pH-metry and manometry the nature of motor dysfunction and whether it improves after surgical cure of reflux. Methods: Sixteen refluxing children aged 131 ± 54 months were studied by combined ambulatory pH-metry and manometry before and more than 6 months after successful fundoplication. pH-metric and manometric variables were compared at both time end-points by paired statistical tests accepting a significance level of P less than.05. Results: Operation cured all patients clinically and pH-metrically, but, in spite of this, only the frequency of motor sequences decreased significantly after the operation from 1 (0.45) to 0.8 (0.6) waves per minute (median [interquartile range]). Wave amplitude and duration were similar in both conditions; the proportion of peristaltic waves was normal and did not change before and after the operation (79.5% [17.25] v 81.4% [21.5]; not significant), whereas the proportions of complete (63.2% [17.5] v 67.8% [19.3]; not significant) and effective (32.4% [31.95] v 27.25% [22.5]; not significant) waves were definitely low and remained so after treatment. Conclusions: The esophagus of children with GER has mild disturbances of peristaltic activity with waves often incomplete, weak, and scarcely effective. Dismotility does not improve after successful fundoplication suggesting that it could be a primary phenomenon. J Pediatr Surg 36:1405-1411. Copyright © 2001 by W.B. Saunders Company.

Laparoscopic repair of paraesophageal hernia.

Surgical repair of paraesophageal hernia is mandatory, due to the risk of severe complications, and it can be accomplished via the laparoscopic route. This study presents the results of laparoscopic repair of paraesophageal hernia combined with anterior hemifundoplication. During a two-year period, ten consecutive patients with paraesophageal hernia (six men, four women; mean age 73, range 55-82) underwent laparoscopic treatment. Five patients presented with symptoms of gastroesophageal reflux, while another four reported lower chest pain. There was one patient in whom the paraesophageal hernia was manifested with upper gastrointestinal bleeding. Six patients had type III hiatal hernia. They all underwent esophagography, upper gastrointestinal endoscopy, stationary manometry, and 24-hour ambulatory pH-metry, preoperatively and within three months postoperatively. At laparoscopy, the hernia content was completely reduced, the sac excised, and the diaphragmatic crura approximated. The operation was completed with an anterior hemifundoplication. In three cases, a prosthetic mesh was applied to close the hiatal defect securely. Operating times ranged from 75 min to 125 min (mean 90 min). There were no postoperative deaths. One patient developed atelectasis, and another had empyema of the left pleura, treated with drainage and antibiotics. All patients but one were discharged on the second or third postoperative day. At the three-month follow-up examination, none of the patients had symptoms related to the paraesophageal hernia, gastroesophageal reflux, or fundoplication. Esophagography demonstrated restoration of normal anatomy at the gastroesophageal region, while esophageal motility was improved, and esophageal pH-metry showed no gastroesophageal reflux. Laparoscopic repair of paraesophageal hernias is a safe, technically feasible, and well tolerated procedure, which offers rapid and total relief of symptoms. The addition of an anterior hemifundoplication not only cures preexisting gastroesophageal reflux, but also prevents the development of postoperative gastroesophageal reflux.