Background: Assessing symptomatic patients following failed fundoplication can be challenging. Although upper endoscopy, and barium esophagography often reveal anatomic abnormalities, functional information allowing insight into the cause of recurrent symptoms can be key to clinical decision making. Previous studies have shown that LES residual pressures or percent LES relaxation measured by postoperative conventional manometry correlates with dysphagia, but it is highly susceptible to interobserver variability. High resolution manometry (HRM) is a novel, imaged based technology which may yield superior, more easily interpreted results in the evaluation of esophageal function particularly given difficult postoperative anatomy. Aim: To study the high resolution manometric characteristics of postfundoplication patients with dysphagia. Patients and
Methods: The study population consisted of 17 patients with foregut symptoms following fundoplication referred between 2005-2007. The most common symptom was dysphagia in 12/17 (71%), regurgitation in 9 (53%), heartburn in 4 (24%), cough in 3 (18%), vomiting in 2 (12%), chest-pain in 5 (29%) and bloating in 1 (6%). HRM studies were analyzed systematically with particular attention to characteristics of the neo-high pressure zone including resting/residual pressure, total and abdominal length and esophageal body function. Values of 50 normal subjects studied in the same laboratory were used as reference. Endoscopy revealed a failed fundoplication in 13/17 patients, 4 patients had no apparent anatomic changes.
Results: Percent LES relaxation was significantly lower (31.4 vs. 76.1), and LES residual pressure was significantly higher (12.1 vs. 6.1) in postfundoplication patients. Eighty eight percent of the patients had lower than normal intra-abdominal LES lengths. There was no significant difference between esophageal body amplitudes. A majority (59%) of post-fundoplication patients had abnormal double-peaked waves suggesting outflow obstruction. The percent LES relaxation in postfundoplication patients with dysphagia was significantly lower than in patients with other symptoms.
Conclusion: HRM revealed high residual pressures and low percent LES relaxations of the neo-high pressure zone in virtually all patients with post-fundoplication dysphagia. Further this measure correlated with the presence of dysphagia. The image based analysis and high density of recording sides coupled with software interpolation available in HRM, allows novel and clinically useful observations in the evaluation of complex esophageal pathology.