Preoperative Esophageal Manometry Research Articles

The Relevance of Ineffective Esophageal Motility to Surgical Practice

Foregut surgery is often complicated by postoperative dysphagia. Preoperative esophageal manometry has been used to counsel patients and to guide choice of operation to minimize dysphagia outcomes. Uncertainty surrounds the optimal surgical management of patients with disordered motility. While treatment protocols are generally accepted for the disorders of esophagogastric junction outflow, surgery choice in the presence of disorders of peristalsis, particularly ineffective esophageal motility (IEM), is less clear. With the diagnosis of IEM, provocation testing is being utilized to predict postoperative dysphagia and to guide management, though evidence is not yet sufficient to allow for strong recommendations.

Do Preoperative Esophageal pH Monitoring and High-Resolution Manometry Predict Symptoms of GERD After Sleeve Gastrectomy?

Predictive factors of evolution or appearance of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) have not been identified to date. We aimed to assess the evolution of GERD symptoms 1 year after SG and to determine preoperative predictive factors using high-resolution manometry (HRM) and ambulatory 24-h esophageal pH monitoring (APM). We included 160 patients who underwent SG between 2013 and 2017 and performed preoperative APM and HRM. Positive APM was defined according to the Lyon consensus. Symptoms of GERD, proton pump inhibitors (PPI) use, weight loss (WL), and diet were recorded in all patients before and 1 year after surgery. One year after surgery, 58 patients (36.3%) complained of GERD symptoms compared to 52 patients (32.5%) preoperatively (p=0.48). Among patients with preoperative GERD symptoms, only 26/52 patients (50%) still had symptoms, whereas 32/108 (29.6%) asymptomatic patients developed de novo GERD symptoms after surgery. PPI use increased after surgery reaching 36.9% of patients against 15.0% before (p<0.0001). Only preoperative symptoms of GERD were predictive of postoperative symptoms (OR= 2.47 [1.14-5.45]; p=0.023) in multivariate analysis. Preoperative manometric parameters, postoperative diet, and WL were not related to postoperative symptoms. In asymptomatic patients before surgery, silent GERD (positive APM without symptom) was predictive of postoperative GERD symptoms (OR=2.69 [1.00-7.25]; p=0.049). Evolution of GERD symptoms after SG reveals improvement for half of the patients and de novo GERD symptoms in one-third of patients. Predictive factors of postoperative symptoms are preoperative symptoms and positive preoperative APM in asymptomatic patients.

Does Roux-en-Y Gastric Bypass Really Cure Gastroesophageal Reflux Disease? Analysis of Objective Data.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the treatment of choice for obesity with gastroesophageal reflux disease (GERD). There are few reports showing objective data based on esophageal function tests (EFTs). The aim of our study was to evaluate the influence of LRYGB on GERD. Methods: Candidates for laparoscopic sleeve gastrectomy (LSG) underwent preoperative esophageal manometry (EM) and 24-hour pH monitoring. Based on the negative influence of LSG on GERD, patients with abnormal pH were offered LRYGB. Those patients repeated EFTs, esophagogastroduodenoscopy, and symptom questionnaire 1 year after surgery. Results: Two hundred fifty LSG candidates underwent preoperative EFTs; 38% were redirected to LRYGB due to abnormal pH and 13 (18%) completed EFTs postoperatively. In ten women, age: 40 ± 7 years, body mass index: 41 ± 1 kg/m2. EM: lower esophageal sphincter (LES) length increased from 2.6 to 2.9 cm (P = not statistically significant [NS]), and LES pressure decreased from 15 to 14.2 mmHg (P = NS). Preoperatively, LES was normotensive in 12 (92%) patients and postoperatively in 11 (85%) (P = NS). DeMeester score decreased from 35.7 to 11 (P < .001). Postoperatively, 9 (69%) patients resolved their GERD, 3 (23%) improved, and 1 (8%) remained the same (P < .001). Symptoms decreased significantly after surgery. Two patients (15%) had Grade A esophagitis. One of them was able to resolve it, while the other 1 remained the same. Conclusions: Our preliminary data showed that after LRYGB, LES pressure remained the same and DeMeester score decreased, while 69% of patients resolved their GERD. Therefore, LRYGB seems to be an excellent option for obesity and GERD.

Laparoscopic floppy Nissen fundoplication: evaluation of outcome in 34 patients operated without prior oesophageal pH and manometry

Background: Aim of the study was to evaluate prospectively the outcomes of laparoscopic floppy Nissen fundoplication in cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD) and hiatus hernia without pre-operative 24 hours oesophageal pH and manometry study. Methods: Thirty-four patients with typical symptoms of GERD, from March 2009 to November 2019, were studied. The study was limited to patients with positive findings on upper GI endoscopy done by operating surgeon with typical symptoms (heartburn, regurgitation, and dysphagia) of GERD and hiatal hernia. Laparoscopic Nissen’s fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only 1 patient, who had negative endoscopic findings, underwent a 24-hour pH-monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome and quality of life after surgery.Result: Laparoscopic Nissen’s fundoplication is an effective long-term treatment for GERD and may be performed in patients with typical symptoms of GERD and hiatus hernia and endoscopic findings suggestive of reflux esophagitis and patient who wants to get rid of life long proton-pump inhibitors (PPI) and antacids medication.Conclusions: Preoperative oesophageal manometry and 24-hour pH monitoring are not mandatory for laparoscopic fundoplication if the patient selection is appropriate but may be required in selected patients with atypical symptoms.

The role of preoperative workup in predicting dysphagia, dilation, or explantation after magnetic sphincter augmentation.

Magnetic sphincter augmentation (MSA) is a surgical treatment for gastroesophageal reflux disease using a ring of titanium beads to improve the function of the lower esophageal sphincter. Prior to implantation, a comprehensive preoperative esophageal workup is required to determine patient candidacy in an effort to reduce the dysphagia, dilation, and explantation rate of the device. This study was designed to assess the best predictors for these endpoints. A prospectively maintained IRB-approved database was retrospectively reviewed for patients undergoing MSA implantation. Patients were divided into 3 groups, those that needed no intervention, those that needed medical intervention with oral steroids for reported dysphagia, and surgical intervention, which included endoscopic dilation and/or surgical explantation. Primary endpoints included preoperative objective and subjective testing from a comprehensive esophageal workup including intraoperative notation of number of beads on the device. There were 99 patients eligible for the study with a mean age of 52 and mean follow-up of 10.2months. Mean BMI was 27 and 59% were female. The no-intervention group had 59 patients, medical intervention group had 25 patients, and surgical intervention group had 15 patients. Preoperative esophageal manometry findings, pH testing off medications, endoscopic and radiologic evaluation showed no difference between the 3 groups. No differences were seen in preoperative subjective evaluations based on GERD-HRQL or RSI scores. There was no difference in average number of beads on the device between the 3 groups. A comprehensive esophageal workup is important to confirm the presence of gastroesophageal reflux disease and rule out other esophageal pathology. However, this study shows that a preoperative comprehensive esophageal workup does not predict which patients will develop dysphagia or require either medical or surgical interventions following MSA implantation.

Manometric Esophageal Length to Height (MELH) Ratio Predicts Hiatal Hernia Recurrence.

The shortened esophagus is poorly defined and is determined intraoperatively, as there exists no objective test to identify a shortened esophagus before surgical hiatal hernia repair. We devised a unique manometric esophageal length to height (MELH) ratio to define the presence of a shortened esophagus and examined the role of esophageal length in hiatal hernia recurrence. A retrospective review identified 254 patients with hiatal hernia who underwent preoperative esophageal manometry and either an open hernia repair with Collis gastroplasty and fundoplication (with Collis) or laparoscopic repair and fundoplication without Collis gastroplasty (without Collis) from 2005-2016. The MELH ratio was calculated by measuring the upper to lower esophageal sphincter distance divided by the patient's height. Of 245 patients, 157 underwent repair with Collis, while 97 underwent repair without Collis. The Collis group had a shorter manometric esophageal length (20.2 vs. 22.4 cm, P<0.001) and lower MELH (0.12 vs. 0.13, P<0.001). The Collis group had fewer hernia recurrences (18% vs. 55%, log-rank P<0.001) and fewer reoperations for recurrence (0% vs. 10%, log-rank P<0.001) at 5 years. A 33% decrease in risk of hernia recurrence was seen for every 0.01 U increment in MELH ratio (hazard ratio: 0.67; 95% confidence interval: 0.55-0.83, P<0.001) while repair without Collis (hazard ratio: 6.1; 95% confidence interval: 3.2-11.7, P<0.001) was associated with increased risk of hernia recurrence. MELH ratio is an objective predictor of a shortened esophagus preoperatively. Lower MELH is associated with increased risk of recurrence and the risk associated with shortened esophagus can be mitigated with an esophageal lengthening procedure such as Collis gastroplasty.

1821 Post-Fundoplication Esophageal Bezoar Resolved With Endoscopic Instillation and Oral Ingestion of Cola

INTRODUCTION: We present a difficult bezoar-like esophageal food impaction which occurred 6 months after repair of a giant Type IV hiatal hernia. CASE DESCRIPTION/METHODS: The patient is an active 90-year-old female who had a giant Type IV paraoesophageal hernia containing stomach and colon for many years. She underwent repair with mesh and a loose Nissen fundoplication (58 Fr). Pre-operative esophageal manometry was not performed. Post-operative esophagram showed intact wrap, with “3 mm minimum diameter central luminal channel through the fundoplication.” Preserved esophageal motility was also noted. Recovery was uneventful. Six months later, she presented to the ED complaining of sensation of food stuck in her throat. She was tolerating secretions and tiny sips of water. Barium esophagram revealed “dilated distal esophagus, with contrast pooling above retained material at the GE junction”. EGD was performed under general anesthesia. The distal esophagus was completely obstructed with food. Despite use of multiple tools including net, rat-tooth forceps and pronged graspers, it could not be cleared. Using small instillations of cola through a 60 cc syringe, we were able to “tunnel” through the impaction and create a lumen into the stomach. Retroflexion showed a small hiatal hernia. After more than 2 hours, there was still a significant amount of food adherent to the walls of the esophagus. The patient was extubated and admitted to the hospital. She was instructed to drink small sips of cola and ice chips upright in bed. She ingested 2 L of cola over the next 8 hours without difficulty. EGD the next day noted complete passage of food. There was no frank ring or stricture. Fundoplication was intact with a small(2 cm) hiatal hernia. She was discharged the same day on soft diet. At follow up with thoracic surgery she had no further dysphagia episodes. She was instructed to drink cola once a day for maintenance. DISCUSSION: Although the patient had a loose wrap and no known dysmotility, post-op diameter of the esophageal lumen was fairly small (3 mm). If patient was not adhering to post-fundoplication diet, this likely precipitated “packing” of food into the distal esophagus and remnant small hernia. Removal of esophageal food impaction is most commonly done by pushing food into the stomach, or removing it mechanically. The use of proteolytic enzymes e.g. papain is not recommended due to perforation risk. One can consider adding cola to the arsenal of tools for safely treating difficult esophageal food impactions.

393 7 Patterns of Esophageal Motility Disorders Detected by Multiple Rapid Swallows

INTRODUCTION: High resolution manometry (HRM) has improved the ability to detect esophageal motility abnormalities. In conjunction with HRM, the Chicago Classification has been widely used to classify these disorders. Provocative tests, such as multiple rapid swallows, are used as a preoperative assessment for GERD and hiatal hernia. Our study assesses the utility of MRS beyond its use as a preoperative assessment. METHODS: After completion of the standard protocol, patients perform multiple rapid swallows under the instruction and supervision of a trained RN. MRS consists of a series of rapid 2-mL swallows at 2-3 second intervals. Patient repeats MRS with the goal of 3-4 MRS. RESULTS: In this cohort, we had a total of 90 patient: 3 patients were excluded from MRS due to high suspicion of achalasia. 5 patients did not complete MRS protocol. 2 cases only tolerated 1 MRS. MRS aided in the diagnosis of 16 patients, with a diagnostic utility of 20%. We identified the following 7 patterns: 1) loss of peristaltic reserve, 2) presence of good reserve, 3) repetitive spasm pattern, 4) unmasking hypercontractility, 5) paradoxical LES contractions, 6) loss of deglutition inhibition, 7) distal esophageal pressurization. CONCLUSION: Currently, HRM studies involve a series of single swallows, which do not represent normal swallowing physiology. In contrast, MRS comprises series of wet swallows, which may better represent deglutition pathophysiology as it inhibits esophageal smooth muscles contraction and relaxes the lower esophageal sphincter (LES). Thus, MRS is hypothesized to serve as a non-invasive substitute to evaluate esophagus integrity. In our study, MRS had a high diagnostic yield in assessing peristaltic reserve, unmasking underlying hypercontractility and esophageal spasm, and confirming true outflow obstruction with pressurization pattern. Pathophysiology was also detected such as paradoxical LES contraction and loss of deglutition inhibition, which helped with diagnosing cases of achalasia variant and esophageal spasm. MRS is an effective, simple, and inexpensive technique to identify esophageal disorders. It was very well tolerated by majority of patients and did not add cost to the procedure. We recommend standardizing MRS in HRM protocol as it provides a better understanding of esophageal disorders. Stoikes, Nathaniel et al. “The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery.” 2012: 3401-7.

Omission of preoperative esophageal manometry does not alter operative approach or postoperative dysphagia following laparoscopic paraesophageal hernia repair.

Routine esophageal manometry for surgical planning before laparoscopic paraesophageal hernia (PEH) has been advocated in an effort to reduce the likelihood of postoperative dysphagia. The purpose of this study is to investigate whether omitting routine preoperative esophageal manometry is associated with a change in the type of fundoplication performed and with an increase in the incidence of postoperative dysphagia. A retrospective cohort study of consecutive patients with and without preoperative esophageal manometry undergoing PEH repair was performed between January 2011 and July 2014 at an academic medical center. Demographic and outcome data were collected in a prospective database. The primary outcome measures were the type of fundoplication performed and postoperative disease-specific quality-of-life (GERD-HRQL) dysphagia score. Secondary outcome measures were total GERD-HRQL score, proton pump inhibitor (PPI) use, and requirement for endoscopic dilation. One hundred twenty-five patients underwent laparoscopic PEH repair. Forty-seven (37%) patients had preoperative manometry and 79 (63%) did not. Patients who did not have manometry were older (67.9 ± 14.3 vs. 61.7 ± 13.5, P = 0.02), but the groups did not differ in terms of BMI, gender, PPI use, baseline GERD-HRQL dysphagia score, or baseline total GERD-HRQL score. Sixty-nine (87%) patients without manometry and 43 (93%) patients with manometry underwent a complete fundoplication (P = 0.55). At a median follow-up of 16 (4-44) months, the median GERD-HRQL dysphagia scores (0(0-1) vs. 0(0-1); P = 0.66) and total GERD-HRQL scores (3(1-8) vs. 4(0-8); P = 0.72) were equivalent between the groups. Equivalent proportion of patients without and with preoperative manometry used PPI (9% vs. 21%; P = 0.06) and required endoscopic dilation (6% vs. 6%; P = 0.99) in the postoperative period. Omission of routine preoperative manometry prior to laparoscopic PEH repair is not associated with a change in the type of fundoplication performed, an increased incidence of postoperative dysphagia, or an increased requirement for postoperative endoscopic dilation.

Tu1334 - The Role of Pre-Operative Esophageal Manometry and PH Monitoring in Bariatric Surgical Procedure Selection

Tu1334 - The Role of Pre-Operative Esophageal Manometry and PH Monitoring in Bariatric Surgical Procedure Selection

Loss of Peristaltic Reserve, Determined by Multiple Rapid Swallows, Is the Most Frequent Esophageal Motility Abnormality in Patients With Systemic Sclerosis.

We assessed peristaltic reserve using multiple rapid swallows (MRS) during esophageal high-resolution manometry (HRM) of 111 patients with systemic sclerosis (89 women; ages, 42-64 y). We performed a retrospective analysis of HRM studies that included MRS in patients with systemic sclerosis, performed at 2 tertiary referral centers, and compared data with those from 18 healthy volunteers (controls). HRM findings were analyzed according to the Chicago Classification to provide an esophageal motility diagnosis. Response to MRS was evaluated for the presence of contraction and for augmentation, defined as the distal contractile integral after MRS greater than the median distal contractile integral of 10 supine swallows. Esophageal motility diagnoses included 41% with absent contractility, 31% with normal motility, 23% with ineffective esophageal motility, and 5% that met the criteria for other esophageal motility disorders. Contraction (37%) and peristaltic augmentation (18%) after MRS were observed less frequently in patients with systemic sclerosis than in controls (83% and 100%, respectively). Impaired peristaltic reserve, as assessed with MRS during HRM, is therefore the most common esophageal motility finding among patients with systemic sclerosis.

Peroral Endoscopic Myotomy for the Treatment of Achalasia

Abstract Introduction: Favorable early results have established peroral endoscopic myotomy (POEM) as a safe and effective treatment for achalasia.1 Current data suggest it results in similar perioperative outcomes when compared with laparoscopic Heller myotomy.2 Although long-term data are currently unavailable, a prospective, international, multicenter clinical trial has demonstrated effectiveness after a mean follow-up period of 10 months.3 Herein we provide a video demonstration (5 minutes 31 seconds) of POEM in a 61-year-old female with 9 months of progressive dysphagia and a 20-pound weight loss. Preoperative upper gastrointestinal and esophageal manometry were consistent with achalasia; esophagogastroduodenoscopy ruled out the presence of additional esophageal pathology. Materials and Methods: After induction of general anesthesia, the abdomen was prepped and draped. The esophagus and stomach were suctioned and irrigated with a simethicone solution. Indigo carmine dye was injected into the anterior ...

The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery

When multiple swallows are rapidly administered, esophageal peristalsis is inhibited, and pronounced lower esophageal sphincter relaxation ensues. After the last swallow of the series, a robust contraction sequence results. The authors hypothesize that multiple rapid swallows (MRS) may have value in predicting esophageal transit symptoms in patients undergoing laparoscopic antireflux surgery (LARS). Records of patients undergoing esophageal high-resolution manometry (HRM) before LARS were evaluated. The evaluation of MRS included adequate inhibitory response during swallows and the contraction pattern after MRS. Dysphagia was scored based on a product of symptom frequency and severity using 5-point Likert scales. A composite dysphagia score comprised the sum of scores for solid and liquid dysphagia, and a score of 4 or higher was considered clinically significant. The normal and abnormal MRS responses of patients with preoperative, early, and late postoperative dysphagia were compared with those of patients with no dysphagia. In this study, 63 patients (mean age, 60.3 ± 1.7 years, 48 women) undergoing HRM before LARS successfully performed MRS (median, 5 swallows; longest interval between swallows, 3.2 ± 0.1 s). After MRS, 14 patients (22.2%) had an intact peristaltic sequence. Complete failure of peristalsis was seen in 21 (33.3%), and incomplete esophageal inhibition in 25 (39.7%) of the remaining patients. When stratified by presence or absence of dysphagia, 58.3% of the subjects without dysphagia had a normal MRS response, whereas 83.3% had formation of peristaltic segments after MRS. In contrast, only 14% of the subjects with dysphagia had a normal MRS response (p ≤ 0.003 vs. the subjects with no dysphagia). Abnormal MRS responses were more prevalent in the patients with any preoperative and late postoperative dysphagia (p = 0.04 across groups) and in those with clinically significant dysphagia (p = 0.08 across groups). High-resolution manometry with MRS helps to predict dysphagia in subjects undergoing preoperative esophageal function testing before LARS.

Laparoscopic fundoplication improves oesophageal motility – a prospective study

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Tarnowski W, Kiciak A, Borycka-Kiciak K, Ciesielski A, Binda A, Dib N. Laparoscopic fundoplication improves oesophageal motility – a prospective study. Videosurgery and Other Miniinvasive Techniques. 2011;6(2):73-83. doi:10.5114/wiitm.2011.23213. APA Tarnowski, W., Kiciak, A., Borycka-Kiciak, K., Ciesielski, A., Binda, A., & Dib, N. (2011). Laparoscopic fundoplication improves oesophageal motility – a prospective study. Videosurgery and Other Miniinvasive Techniques, 6(2), 73-83. https://doi.org/10.5114/wiitm.2011.23213 Chicago Tarnowski, Wiesław, Adam Kiciak, Katarzyna Borycka-Kiciak, Adam Ciesielski, Artur Binda, and Naser Dib. 2011. "Laparoscopic fundoplication improves oesophageal motility – a prospective study". Videosurgery and Other Miniinvasive Techniques 6 (2): 73-83. doi:10.5114/wiitm.2011.23213. Harvard Tarnowski, W., Kiciak, A., Borycka-Kiciak, K., Ciesielski, A., Binda, A., and Dib, N. (2011). Laparoscopic fundoplication improves oesophageal motility – a prospective study. Videosurgery and Other Miniinvasive Techniques, 6(2), pp.73-83. https://doi.org/10.5114/wiitm.2011.23213 MLA Tarnowski, Wiesław et al. "Laparoscopic fundoplication improves oesophageal motility – a prospective study." Videosurgery and Other Miniinvasive Techniques, vol. 6, no. 2, 2011, pp. 73-83. doi:10.5114/wiitm.2011.23213. Vancouver Tarnowski W, Kiciak A, Borycka-Kiciak K, Ciesielski A, Binda A, Dib N. Laparoscopic fundoplication improves oesophageal motility – a prospective study. Videosurgery and Other Miniinvasive Techniques. 2011;6(2):73-83. doi:10.5114/wiitm.2011.23213.

The evaluation of esophageal motility in patients with persistent dysphagia after fundoplication

Persistent postoperative dysphagia (PPD) is a relatively rare but troublesome complication of laparoscopic fundoplication in patients with gastroesophageal reflux disease. Although it is mainly attributed to impaired distal esophageal body (EB) function, it may develop in patients with preserved motility as well. Since little is known about the pre- and postoperative motility patterns of such patients we aimed to compare the esophageal motor function in patients with PPD and a matched control group of patients without swallowing problems after fundoplication. Patients, Methods: Eleven patients (M/F 3/8, mean age: 52.6 ys., BMI: 24.2) with PPD after laparoscopic fundoplication were evaluated. Standard water perfusion esophageal manometry was performed before and 3 months after fundoplication in all subjects and results were compared to an age, sex, BMI and preoperative dysphagia score matched group of 11 control patients without PPD. Results: Preoperative esophageal manometry showed similar lower esophageal sphincter (LES) length, pressure, relaxation time, and EB peristaltic wave duration in both groups. The amplitude of contractions in the distal EB were also similar, while patients with PPD had significantly lower amplitudes in the proximal esophagus than controls after dry (25.5 vs. 61.8mmHg, p=0.01) and wet (45.1 vs. 76.7mmHg, p=0.05) swallows. Propagation velocity of the contractions were slower in patients with PPD after wet swallows (2.56 vs. 3.27cm/s, p=0.05). The number of simultaneous contractions tended to be higher in PPD. Postoperatively both groups had similarly improved LES function. In the EB, distal contraction amplitudes were decreased in patients with PPD (95.6 vs. 75.5mmHg, p=0.05) but not in controls, compared to the preoperative values. After fundoplication the number of simultaneous contractions were significantly higher in patients with PPD than in controls. Conclusions: In patients with preserved distal EB contraction amplitudes, decreased peristaltic wave propagation velocity, and proximal amplitudes may be predictive for PPD after fundoplication. Patients with PPD have decreased distal EB contraction amplitudes after fundoplication compared to their preoperative results. TÁMOP421/B09/1, ETT340/09

Is oesophageal manometry a must before laparoscopic fundoplication? Analysis of 46 consecutive patients treated without preoperative manometry.

AIMS:To evaluate retrospectively the outcome of laparoscopic fundoplication in a cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD).MATERIALS AND METHODS:Forty-six patients with typical symptoms of GERD, from March 2001 to November 2009, were studied. The study was limited to patients with positive findings on upper GI endoscopy done by ourselves and “typical” symptoms (heartburn, regurgitation, and dysphagia) of GERD. Laparoscopic Nissen’s fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only 1 patient, who had negative endoscopic findings, underwent a 24-hour pH-monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient’s evaluation of outcome and quality of life after surgery.RESULTS:Relief of the primary symptom responsible for surgery was achieved in 85% of patients at a mean follow-up of 28 months. Thirty-nine patients were asymptomatic, 2 had minor gastrointestinal symptoms not requiring medical therapy, 3 patients had gastrointestinal symptoms requiring medical therapy/ Proton Pump Inhibitors and in 2 patients the symptoms worsened after surgery. There were no deaths. Clinically significant complications occurred in 6 patients. Median hospital stay was 3 days, decreasing from 6 in the first 10 patients to 3 in the last 10 patients.CONCLUSIONS:Preoperative oesophageal manometry is not mandatory for laparoscopic fundoplication done in selected patients with typical symptoms of GERD and upper GI endoscopy suggestive of large hiatus hernia.

Laparoscopic Heller-Dor Surgery for Esophageal Achalasia: Impact of Intraoperative Real-Time Manometric Feedback on Postoperative Outcomes

Background: Laparoscopic Heller myotomy with Dor fundoplication (LHD) is one of the most established surgical procedures for esophageal achalasia. Preoperative esophageal manometry has been reported as useful to evaluate lower esophageal sphincter (LES) pressure. However, the feasibility, safety, and impact of its intraoperative use have not been fully evaluated, especially when enhanced with real-time 3-D pressure imaging. Methods: LHD was attempted on 24 consecutive patients with esophageal achalasia. Manometry was performed at 3 time points during LHD: before myotomy, after myotomy, and after fundoplication. Investigations included esophagography, manometry, and 24-hour esophageal pH monitoring in the preoperative, short-term (0–5 months) and long-term (1–3 years) follow-up periods. Results: The 3-D intraoperative manometric images were presented to the surgical crew on a monitor screen immediately after each measurement in all attempted cases (n = 13). Any residual high pressure zone of the LES was easily recognized and resolved with additional myotomy. Postoperative esophagographies showed resolution of esophageal dilatation. Manometric examination revealed significant reduction of LES pressure in the short-/long-term follow-up periods. PH monitoring showed no increase in acid reflux. Overall outcomes were satisfactory (symptom relief = 95%). Conclusion: Intraoperative manometry with real-time pressure feedback is a feasible, safe, and useful adjunct in LHD.

Diagnosis and treatment of megaesophagus after adjustable gastric banding for morbid obesity

Background Laparoscopic adjustable gastric banding (LAGB) can impair esophageal peristalsis and can also cause a lack of relaxation of the lower esophageal sphincter, possibly leading to esophageal dilation. The aim of the present study was to determine the incidence of megaesophagus, the role of preoperative manometry in predicting its occurrence, and the management of megaesophagus after gastric banding in the setting of a research clinic. Methods We performed a retrospective review of a prospectively collected database. A total of 257 patients underwent LAGB from January 2002 to December 2006. The incidence of megaesophagus, its relationship to the preoperative esophageal manometry and upper gastrointestinal series findings, and the treatment of patients with this complication were analyzed. Results Of the 257 patients, 5 (1.9%) presented with megaesophagus after gastric banding. The mean interval to development was 32 months (range 24–36). The diagnosis was made using the symptoms, signs, and upper gastrointestinal series findings. The preoperative esophageal manometry findings were normal in 4 (80%) of these 5 patients, and 1 patient (20%) had a nonspecific motility disorder. The mean age was 54.5 years (range 30–76). The mean preoperative weight was 127.1 kg (range 112.7–145.9), and the body mass index was 43.2 kg/m 2 (range 41–49). In all cases, the management of megaesophagus was gastric band removal. All the patients improved partially after band deflation but required band removal because of continued symptoms. Conclusion Megaesophagus is a possible late complication after LAGB. The preoperative manometry results cannot predict for its occurrence. The management of megaesophagus caused by LAGB requires, in most cases, band removal.

Authors' reply: Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry (Br J Surg 2008; 95: 57–63)

Authors' reply: Randomized clinical trial of laparoscopic total (Nissen) <i>versus</i> posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry (<i>Br J Surg</i> 2008; 95: 57–63)

Is Preoperative Manometry in Restrictive Bariatric Procedures Necessary?

Restrictive bariatric procedures are frequently considered for patients with morbid obesity, because the weight loss and reduction of comorbidities are good. An impact on gastroesophageal reflux disease (GERD), which is common in this population, may be anticipated. Converse results of GERD symptoms are reported for patients after adjustable gastric banding (AGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGBP). A literature search was performed and, with our personal experience, are summarized. Esophageal manometry is a practical tool to identify functional disorders of the esophageal body and the lower esophageal sphincter (LES). For patients with weak esophageal body motility, AGB should not be considered as a therapeutic option because esophageal dilation, esophageal stasis, and consequent esophagitis often occur during long-term follow-up, and band deflation is inevitable. Stable body weight can therefore not be achieved in these patients. Low resting pressure of the LES may be a contraindication for SG, because taking away the angle of His further impairs the antireflux mechanism at the cardia. So far, RYGBP is an option for all morbidly obese patients regardless of the results of esophageal manometry. Preoperative esophageal manometry is advised for restrictive procedures such as AGB and SG.