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Role of Esophageal Functions Tests

Carlos Galvani, MD; Piero M. Fisichella, MD; Maria V. Gorodner, MD; Silvana Perretta, MD; Marco G. Patti, MD

Arch Surg. 2003;138:514-519.

Background  If a patient develops foregut symptoms after a fundoplication, it is assumed that the operation has failed, and acid-reducing medications are often prescribed. Esophageal function tests (manometry and pH monitoring) are seldom performed early in the management of these patients.

Hypothesis  In patients who are symptomatic after fundoplication for gastroesophageal reflux disease, a symptom-based diagnosis is not accurate, and esophageal function tests should be performed routinely before starting acid-reducing medications.

Design  Prospective study.

Setting  University hospital.

Patients and Methods  One hundred twenty-four patients who developed foregut symptoms after laparoscopic fundoplication (average, 17 months postoperatively) underwent esophageal manometry and pH monitoring. Sixty-two patients (50%) were taking acid-reducing medications.

Main Outcome Measures  Postoperative symptoms, use of antireflux medications, grade of esophagitis, esophageal motility, and DeMeester scores.

Results  Seventy-six (61%) of the 124 patients had normal esophageal acid exposure, while the acid exposure was abnormal in 48 patients (39%). Only 20 (32%) of the 62 patients who were taking acid-reducing medications had reflux postoperatively. Regurgitation was the only symptom that predicted abnormal reflux.

Conclusions  These results show that (1) symptoms were due to reflux in 39% of patients only; (2) with the exception of regurgitation, symptoms were an unreliable index of the presence of reflux; and (3) 68% of patients who were taking acid-reducing medications postoperatively had a normal reflux status. Esophageal function tests should be performed early in the evaluation of patients after fundoplication to avoid improper and costly medical therapy.

From the Department of Surgery and Swallowing Center, University of California–San Francisco, San Francisco.

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