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THE ROLE OF ESOPHAGEAL MANOMETRY PRIOR TO ANTI-REFLUX SURGERY
A Lazarescu, WG Paterson
GI Diseases Research Unit, Queen’s University, Kingston, Ontario
BACKGROUND: Gastroesophageal reflux disease (GERD) is a common condition that gives rise to many uncomfortable symptoms as well as chronic complications. GERD can be managed medically with proton pump inhibitors or surgically. Esophageal dysmotility can occur as a result of the GERD itself or due to other causes independent of the reflux. There have been concerns in the literature that patients with GERD and esophageal dysmotility may have worse postoperative outcomes and esophageal motility testing prior to anti-reflux surgery is recommended by some medical societies. The purpose of this study is to review the 10-year experience in Kingston, Ontario with patients being considered for anti-reflux surgery, and to determine whether finding preoperative esophageal dysmotility made any difference to clinical decision making and postoperative outcomes.
METHODS: Retrospective chart review of esophageal manometry studies performed between January 1, 1997 and December 31, 2006 as preoperative assessment for anti-reflux surgery as well as chart review to determine outcomes
RESULTS: 112 patients had an esophageal manometry study with the indication “consideration for anti-reflux surgery”. 54% of patients were male. Mean age was 43 years. Forty-nine patients (44%) had a hypotensive lower esophageal sphincter (LES) and/or low peristaltic wave amplitude in the distal esophagus, consistent with esophageal dysmotility secondary to chronic GERD. This is not a contraindication to anti-reflux surgery. However, 28 patients (25%) had other significant manometric abnormalities, including 7 patients with nutcracker esophagus, 4 patients with scleroderma esophagus, and 1 patient with achalasia. These were all new diagnoses. Surgery was cancelled in the scleroderma and achalasia patients on the basis of the manometric findings. The other 16 patients had non-specific esophageal dysmotility and half of them went on to either laparoscopic or open Nissen fundoplication with good symptom relief and minimal complications.
CONCLUSIONS: Esophageal motility studies are useful in identifying patients with primary esophageal motor disorders and help them avoid anti-reflux surgery that may be inappropriate or likely to worsen their symptoms. Patients with symptoms of GERD and non-specific esophageal dysmotility do well after anti-reflux surgery.