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Gastroesophageal Reflux Disease and Antireflux Surgery—What Is the Proper Preoperative Work-up?

  • 2012 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD).

Aims

The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS.

Patients and Methods

One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient.

Results

Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n = 78, 58 %) and GERD− (n = 56, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD− patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD− patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups.

Conclusions

The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave., MC 5095, Chicago, IL, 60637, USA

    Brian Bello, Marco Zoccali, Roberto Gullo, Marco E. Allaix, Fernando A. Herbella & Marco G. Patti

  2. Department of Radiology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA

    Arunas Gasparaitis

Authors
  1. Brian Bello
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  2. Marco Zoccali
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  3. Roberto Gullo
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  4. Marco E. Allaix
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  5. Fernando A. Herbella
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  6. Arunas Gasparaitis
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  7. Marco G. Patti
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Corresponding author

Correspondence to Marco G. Patti.

Additional information

Discussant

Dr. Steven Bowers (Jacksonville, FL): Dr. Patti was the primary author of a similar but substantially larger study published over 10 years ago. This very important prior work established the diagnostic inaccuracy of reflux symptoms and highlighted the finding of erosive esophagitis in approximately 10 % of the patients with normal esophageal acid exposure.

Question 1: This study is somewhat a reiteration of Dr. Patti’s prior work. How does this work improve upon the senior author’s previously published work?

Question 2: With the availability of multichannel esophageal impedance and 48-h esophageal pH testing, is 24-h pH testing still the diagnostic gold standard?

Question 3: If erosive esophagitis is not caused by reflux of gastroduodenal contents, what do the authors suspect in the etiology of the erosive disease in patients negative to 24-h pH testing?

Question 4: Did the authors perform Nissen fundoplication in all GERD-positive patients, and do they discount the finding of hypoperistalsis or spastic motor disorder on high-resolution motility in patients with GERD diagnosis?

Question 5: Do the authors consider laryngopharyngeal reflux (LPR) as an entity separate from GERD, as it does not appear that any LPR patients were included in analysis?

Closing Discussant

Dr. Brian L. Bello:

1. Patients in the previous study were referred to our Esophageal Center to complete their work-up and to confirm a diagnosis of GERD that had been based on symptoms and endoscopy. The current study consists of patients who were referred for antireflux surgery with a presumed diagnosis of GERD. The implications are different, as we have now shown that symptoms, endoscopy, and a barium swallow are not sufficient as preoperative work-up before antireflux surgery and that pH monitoring should always be performed as it helps avoiding unnecessary surgery.

2. Yes, we feel that in most patients, the 24-h ambulatory pH monitoring test is still the gold standard. In selected patients, both impedance pH testing and a 48-h test have a role.

3. We did not distinguish between erosive and nonerosive esophagitis in our study. Many patients were referred from outside of University of Chicago and had endoscopy reports not making that distinction.

4. We also use manometry to help guide the type of fundoplication. For example, we will perform a partial fundoplication if there is documented aperistalsis. We do favor a Dor fundoplication over a Toupet fundoplication as it is an easier operation to perform with no need for a posterior dissection.

5. We did not separate this group apart for analysis.

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Bello, B., Zoccali, M., Gullo, R. et al. Gastroesophageal Reflux Disease and Antireflux Surgery—What Is the Proper Preoperative Work-up?. J Gastrointest Surg 17, 14–20 (2013). https://doi.org/10.1007/s11605-012-2057-5

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  • DOI: https://doi.org/10.1007/s11605-012-2057-5

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