Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing

Abstract

Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient's peristaltic reserve prior to surgery.

Keywords: Anti-reflux surgery; Fundoplication; Gastroesophageal reflux disease; High resolution manometry; Pre-operative assessment; pH-impedance.

Figure 1

Twenty-four hours pH studies. A: Normal 24 h pH study showing acid in the stomach without acid reflux events in the esophagus; B: Abnormal 24 h pH monitoring test with multiple acid reflux events in the esophagus (star indicating reflux events).

Figure 2

Abnormal wireless capsule pH study (arrows indicating prolonged reflux events).

Figure 3

Examples of pH-impedance measurements. A: Reflux event recorded during 48 h pH-impedance study; B: Weak acid reflux event in the esophagus without acid exposure in the stomach detected on pH-impedance study (arrows indicating impedance events, star indicating pH drop and acid event).

Figure 4

Utility of pH and multichannel intraluminal impendence pH testing for pre-operative assessment. GERD: Gastroesophageal reflux disease; NERD: Non-erosive reflux disease; PPI: Proton pump inhibitor; AET: Acid exposure time; MII-pH: Multichannel intraluminal impendence pH monitoring.

Figure 5

Utility of high-resolution manometry for pre-operative assessment. LES: Lower esophageal sphincter.

Figure 6

Normal peristalsis and lower esophageal sphincter relaxation on high-resolution manometry. A: Example of normal swallow on high-resolution manometry; B: Normal swallow with complete esophageal clearance by impedance.

Figure 7

Examples of achalasia diagnosed on high-resolution manometry. A: Type I achalasia with failure of lower esophageal sphincter relaxation and absence of peristalsis; B: Type II achalasia with panesophageal pressurization; C: Type III achalasia with abnormal peristalsis (spastic/premature contractions).

Figure 8

Scleroderma esophagus with absent peristalsis and hypotensive lower esophageal sphincter.

Figure 9

Outflow obstruction with elevated residual pressure and distal pressurization from chronic opioid use.

Figure 10

Example of hypercontractile esophagus with distal contractile integral > 8000 mmHg.

Figure 11

Findings on high-resolution manometry with multiple rapid swallow. A: Normal multiple rapid swallow (MRS) with good contraction distal contractile integral; B: Weak esophageal contractions with MRS; C: Failed esophageal contractions with MRS.

Figure 12

Examples of straight leg raise testing during high-resolution manometry. A: Normal straight leg raise test with single pressurization zone; B: Two pressurization zones after straight leg raise indicating presence of small hiatal hernia; C: Example of two pressurization zones after straight leg raise in patient with large hiatal hernia (Arrows indicate pressurization zones).