Surgical Endoscopy

, Volume 26, Issue 12, pp 3401–3407 | Cite as

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

  • Nathaniel Stoikes
  • Jesse Drapekin
  • Vladimir Kushnir
  • Anisa Shaker
  • L. Michael Brunt
  • C. Prakash GyawaliEmail author



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.


Dysphagia Esophageal manometry Laparoscopic antireflux surgery Multiple rapid swallows 



L. Michael Brunt has received honoraria for speaking and teaching from Ethicon Endosurgery and Lifecell Corporation. C. Prakash Gyawali has received honoraria for speaking and research support from Given Imaging. Nathaniel Stoikes, Jesse Drapekin, Vladimir Kushnir, and Anisa Shaker have no conflicts of interest or financial ties to disclose.


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Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Nathaniel Stoikes
    • 1
  • Jesse Drapekin
    • 2
  • Vladimir Kushnir
    • 2
  • Anisa Shaker
    • 2
  • L. Michael Brunt
    • 1
  • C. Prakash Gyawali
    • 2
    Email author
  1. 1.Section of Minimally Invasive SurgeryWashington University School of MedicineSt. LouisUSA
  2. 2.Division of GastroenterologyWashington University School of MedicineSt. LouisUSA

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