title: Value of preoperative esophageal function studies before laparoscopic antireflux surgery.
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.
authors.affiliation: Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Walter W
authors.initials: WW
authors.lastname: Chan
authors.forename: Laura R
authors.initials: LR
authors.lastname: Haroian
authors.forename: C Prakash
authors.initials: CP
authors.lastname: Gyawali
mesh_terms: D015331:Cohort Studies; D000075202:Contraindications; D015154:Esophageal Motility Disorders / Q000150:complications / Q000175:diagnosis* / Q000503:physiopathology; D050782:Esophageal pH Monitoring; D004947:Esophagus / Q000503:physiopathology*; D005260:Female; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000150:complications / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D018670:Monitoring, Ambulatory; D011300:Preoperative Care / Q000379:methods*; D012189:Retrospective Studies