title: Ineffective esophageal motility phenotypes following fundoplication in gastroesophageal reflux disease.
abstract: BACKGROUND
  Ineffective esophageal motility (IEM) is associated with reflux disease, but its natural history is unclear. We evaluated patients undergoing repeat esophageal high resolution manometry (HRM) for symptomatic presentations after antireflux surgery (ARS) to understand the progression of IEM.
  
  
  METHODS
  Patients with repeat HRM after ARS were included. Ineffective esophageal motility was diagnosed if ≥5 sequences had distal contractile integral (DCI) <450 mmHg cm s. Augmentation of DCI following multiple rapid swallows (MRS) was assessed. The esophagogastric junction (EGJ) was interrogated using the EGJ contractile integral (EGJ-CI). Esophageal motor function was compared between patients with and without IEM.
  
  
  RESULTS
  Sixty-eight patients (53.9 ± 1.8 years, 66.2% female) had pre- and post-ARS HRM studies 2.1 ± 0.19 years apart. Esophagogastric junction-CI augmented by a mean of 26.3% following ARS. Four IEM phenotypes were identified: 14.7% had persistent IEM, 8.8% resolved IEM after ARS, 19.1% developed new IEM, and 57.4% had no IEM at any point. Patients with IEM had a lower DCI pre- and post-ARS, lower pre-ARS EGJ CI, and lower pre-ARS-integrated relaxation pressure (p ≤ 0.02 for all comparisons); presenting symptoms and other EGJ metrics were similar (p ≥ 0.08 for all comparisons). The IEM phenotypes could be predicted by MRS DCI response patterns (p = 0.008 across groups); patients with persistent IEM had the least DCI augmentation (p = 0.007 compared to no IEM), while those who resolved IEM had DCI augmentation comparable to no IEM (p = 0.08).
  
  
  CONCLUSIONS
  Distinct phenotypes of IEM exist among symptomatic reflux patients following ARS. Provocative testing with MRS may help identify these phenotypes pre-ARS.
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: M D
authors.initials: MD
authors.lastname: Mello
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: A R
authors.initials: AR
authors.lastname: Shriver
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: Li
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: A
authors.initials: A
authors.lastname: Patel
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA.
authors.forename: C P
authors.initials: CP
authors.lastname: Gyawali
mesh_terms: D000368:Aged; D015154:Esophageal Motility Disorders / Q000150:complications*; D005260:Female; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000150:complications* / Q000601:surgery*; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D010641:Phenotype
keywords: gastroesophageal reflux disease; high resolution manometry; ineffective esophageal motility; multiple rapid swallows