title: Investigation of Dysphagia After Antireflux Surgery by High-resolution Manometry: Impact of Multiple Water Swallows and a Solid Test Meal on Diagnosis, Management, and Clinical Outcome.
abstract: OBJECTIVE
  Management of patients with dysphagia, regurgitation, and related symptoms after antireflux surgery is challenging. This prospective, case-control study tested the hypothesis that compared with standard high-resolution manometry (HRM) with single water swallows (SWS), adding multiple water swallows (MWS) and a solid test meal increases diagnostic yield and clinical impact of physiological investigations.
  
  
  METHODS
  Fifty-seven symptomatic and 12 asymptomatic patients underwent HRM with SWS, MWS, and a solid test meal. Dysphagia and reflux were assessed by validated questionnaires. Diagnostic yield of standard and full HRM studies with 24-hour pH-impedance monitoring was compared. Pneumatic dilatation was performed for outlet obstruction on HRM studies. Clinical outcome was assessed by questionnaires and an analogue scale with "satisfactory" defined as at least 40% symptom improvement requiring no further treatment.
  
  
  RESULTS
  Postoperative esophagogastric junction pressure was similar in all groups. Abnormal esophagogastric junction morphology (double high pressure band) was more common in symptomatic than in control patients (13 of 57 vs 0 of 12, P = .004). Diagnostic yield of HRM was 11 (19%), 11 (19%), and 33 of 57 (58%), with SWS, MWS, and solids, respectively (P < .001); it was greatest for solids in patients with dysphagia (19 of 27, 70%). Outlet obstruction was present in 4 (7%), 11 (19%), and 15 of 57 patients (26%) with SWS, MWS, and solids, respectively (P < .009). No asymptomatic control had clinically relevant dysfunction on solid swallows. Dilatation was performed in 12 of 15 patients with outlet obstruction during the test meal. Symptom response was satisfactory, good, or excellent in 7 of 12 (58%) with no serious complications.
  
  
  CONCLUSIONS
  The addition of MWS and a solid test meal increases the diagnostic yield of HRM studies in patients with symptoms after fundoplication and identifies additional patients with outlet obstruction who benefit from endoscopic dilatation.
authors.affiliation: Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
authors.forename: Yu Tien
authors.initials: YT
authors.lastname: Wang
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Ling Fung
authors.initials: LF
authors.lastname: Tai
authors.affiliation: Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
authors.forename: Etsuro
authors.initials: E
authors.lastname: Yazaki
authors.affiliation: Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
authors.forename: Jafar
authors.initials: J
authors.lastname: Jafari
authors.affiliation: Department of Gastroenterology, St Thomas' Hospital, London, United Kingdom.
authors.forename: Rami
authors.initials: R
authors.lastname: Sweis
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Emily
authors.initials: E
authors.lastname: Tucker
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Kevin
authors.initials: K
authors.lastname: Knowles
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Jeff
authors.initials: J
authors.lastname: Wright
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Saqib
authors.initials: S
authors.lastname: Ahmad
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Madhavi
authors.initials: M
authors.lastname: Kasi
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom.
authors.forename: Katharine
authors.initials: K
authors.lastname: Hamlett
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom; Zürich Neurogastroenterology and Motility Research Group, Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland. Electronic address: dr.mark.fox@gmail.com.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Fox
authors.affiliation: Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.
authors.forename: Daniel
authors.initials: D
authors.lastname: Sifrim
mesh_terms: D000328:Adult; D000368:Aged; D000818:Animals; D016022:Case-Control Studies; D003680:Deglutition Disorders / Q000175:diagnosis* / Q000628:therapy; D003955:Diagnostic Tests, Routine / Q000379:methods*; D005260:Female; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006801:Humans; D008297:Male; D008365:Manometry / Q000379:methods*; D008875:Middle Aged; D011446:Prospective Studies; D013514:Surgical Procedures, Operative / Q000009:adverse effects*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D055815:Young Adult
keywords: Dysphagia; Fundoplication; High-resolution Manometry; Provocative Tests; Reflux; Solid Swallows; Water Swallows