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Value of preoperative esophageal function studies before laparoscopic antireflux surgery

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Abstract

Background

The value of esophageal manometry and ambulatory pH monitoring before laparoscopic antireflux surgery (LARS) has been questioned because tailoring the operation to the degree of hypomotility often is not required. This study evaluated a consecutive cohort of patients referred for esophageal function studies in preparation for LARS to determine the rates of findings that would alter surgical decisions.

Methods

High-resolution manometry (HRM) was performed for each subject using a 21-lumen water-perfused system, and motor function was characterized. Gastroesophageal reflux disease (GERD) was evident from ambulatory pH monitoring if thresholds for acid exposure time and/or positive symptom association probability were passed.

Results

Of 1,081 subjects (age, 48.4 ± 0.4 years; 56.7% female) undergoing preoperative HRM, 723 (66.9%) also had ambulatory pH testing performed. Lower esophageal sphincter (LES) hypotension (38.9%) and nonspecific spastic disorder (NSSD) of the esophageal body (36.1%) were common. Obstructive LES pathophysiology was noted in 2.5% (achalasia in 1%; incomplete LES relaxation in 1.5%), and significant esophageal body hypomotility in 4.5% (aperistalsis in 3.2%; severe hypomotility in 1.3%) of the subjects. Evidence of GERD was absent in 23.9% of the subjects. Spastic disorders were more frequent in the absence of GERD (43.9% vs. 23.1% with GERD; p < 0.0001), whereas hypomotility and normal patterns were more common with GERD.

Conclusions

Findings considered absolute or relative contraindications for standard 360º fundoplication are detected in 1 of 14 patients receiving preoperative HRM. Additionally, spastic findings associated with persistent postoperative symptoms are detected at esophageal function testing that could be used in preoperative counseling and candidate selection. Physiologic testing remains important in the preoperative evaluation of patients being considered for LARS.

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Acknowledgments

The authors acknowledge the contributions of the late Ray E. Clouse, Professor of Medicine and Psychiatry at Washington University School of Medicine, to the field of esophagology in general and to this project in particular. The concepts evaluated in this report were conceived in collaboration with Dr. Clouse, but he passed away before the manuscript could be completed. This article is therefore dedicated to his memory.

Disclosures

C. Prakash Gyawali has received research support from Medtronic and Sierra Scientific, Inc., and is in the Speaker’s Bureau for Sierra Scientific, currently part of Given Imaging. Neither of these represent a conflict of interest relevant to this work. Walter W. Chan and Laura R. Haroian, have no conflicts of interest or financial ties to disclose.

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Authors and Affiliations

  1. Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, USA

    Walter W. Chan

  2. Barnes-Jewish Hospital, St. Louis, MO, USA

    Laura R. Haroian & C. Prakash Gyawali

  3. Division of Gastroenterology, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8124, St. Louis, MO, 63110, USA

    C. Prakash Gyawali

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  1. Walter W. Chan
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  2. Laura R. Haroian
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  3. C. Prakash Gyawali
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Correspondence to C. Prakash Gyawali.

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Chan, W.W., Haroian, L.R. & Gyawali, C.P. Value of preoperative esophageal function studies before laparoscopic antireflux surgery. Surg Endosc 25, 2943–2949 (2011). https://doi.org/10.1007/s00464-011-1646-9

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  • DOI: https://doi.org/10.1007/s00464-011-1646-9

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