High-resolution manometry in evaluation of factors responsible for fundoplication failure.
BACKGROUND
From 10% to 25% of patients undergoing antireflux procedures eventually redevelop symptoms as a result of anatomic failure of the hiatal repair or fundoplication. High-resolution manometry (HRM) allows for reliable evaluation of the lower esophageal sphincter (LES) in detail, including subtle evidence of a hiatus hernia. The aim of this study was to characterize the dynamics and function of the LES postoperatively using HRM to determine which elements may contribute to recurrent symptoms after antireflux surgery.


METHODS
Twenty-three patients with recurrent symptoms and/or abnormal 24-hour pH monitoring after Nissen fundoplication (Unsuccessful group) and 11 asymptomatic post-Nissen patients tested as routine follow-up (Successful group) underwent HRM. Tracings were analyzed for percentage of peristalsis, LES pressure, length of the high-pressure zone (HPZ), LES residual pressure, and the presence of a dual HPZ (indicating a recurrent hiatus hernia). Results were compared between the 2 groups.


RESULTS
Mean LES pressure tended to be greater in the Successful group compared with the Unsuccessful group (p = 0.068). There were no differences in length of the HPZ, residual pressures, and peristalsis. A dual HPZ was identified in 13 Unsuccessful group patients (56%), and 1 (9%) of the Successful group patients (p < 0.05). Abnormal DeMeester scores were observed in 79% of patients with a dual HPZ, compared with 35% of patients without a dual HPZ (p < 0.05).


CONCLUSIONS
The presence of a dual HPZ on HRM in patients after fundoplication appears to be a strong predictor of recurrent gastroesophageal reflux disease. In patients with recurrent symptoms after antireflux surgery, HRM also provides valuable information about peristalsis and LES characteristics that help guide appropriate management.
Tatum
Roger P
RP
Department of Surgery, University of Washington, Seattle, WA 98108, USA.
Soares
Renato V
RV
Figueredo
Edgar
E
Oelschlager
Brant K
BK
Pellegrini
Carlos A
CA
D049630:Esophageal Sphincter, Lower / Q000503:physiopathology*; D050782:Esophageal pH Monitoring; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery*; D006551:Hernia, Hiatal / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011237:Predictive Value of Tests; D012008:Recurrence; D012189:Retrospective Studies; D017211:Treatment Failure