Esophageal Manometry and Clinical Outcome After Laparoscopic Nissen Fundoplication

Abstract

Introduction The outcome after laparoscopic Nissen fundoplication can be assessed by either clinical symptoms or objective tests. Outcomes from objective tests are often held in higher regard than clinical data when determining the merits, or otherwise, of various antireflux surgery procedures. In this study, we sought to determine whether there is a relationship between postoperative symptoms and parameters measured by esophageal manometry to determine whether early postoperative esophageal manometry is a useful investigation for the routine assessment of post fundoplication outcome. Methods One hundred and forty-three patients who had undergone a laparoscopic Nissen fundoplication, clinical follow-up at 3 months and 5 years after surgery, and esophageal manometry at 3 months after fundoplication as part of routine followup in 1 of 5 clinical trials were studied. Nineteen of these patients also underwent manometry 5 years after fundoplication. Postoperative symptoms were prospectively determined by applying a standardized questionnaire, which assessed dysphagia, heartburn, bloat symptoms, and overall satisfaction using analog scales. Patients were classified into different groups according to the analog scores for clinical symptoms. Correlations between clinical and postoperative manometry outcomes were sought. Results No significant associations were found between parameters measured by esophageal manometry (lower esophageal sphincter resting and residual relaxation pressures, peristaltic amplitude and normal peristaltic propagation) and clinical parameters (dysphagia, heartburn, bloating, and overall satisfaction) for all time points-3 months postoperative manometry vs symptoms at 3 months and 5 years, 5 years postoperative manometry vs symptoms at 5 years, except for a weak (r=−0.17, p= 0.042) correlation between the percentage of successfully propagated swallows at 3 months and dysphagia for solids at 5 years. Conclusion Postoperative esophageal manometry parameters at 3 months and 5 years after surgery were not associated with any clinically important differences in the postoperative symptoms of heartburn, dysphagia, bloat or with overall satisfaction with the surgical outcome. The routine use of esophageal manometry to assess the outcome after Nissen fundoplication does not predict clinical outcome.

A meta‐analysis comparing laparoscopic partial versus Nissen fundoplication

“…In addition, previous evidence revealed that post‐operative oesophageal manometry parameters were not associated with any surgical outcome. Other modalities of objective evaluation such as combined multichannel intraluminal impedance and pH‐metry may also have some flaws 47,48 …”

Pseudoachalasia secondary to bariatric surgery

“…12,13 In conclusion, we postulate that bariatric surgery may lead to an achalasia-like syndrome when there is functional obstruction just distal to the esophagus. First, the cause of the highpressure zone can be a narrowed gastrojejunostomy, gastroplasty, or a sleeve gastrectomy.…”

“…Further, it is unlikely that preoperative esophageal manometry would be helpful as previous reports of postoperative dysphagia associated with Nissen fundoplication have shown poor predictive value. 12,13 In conclusion, we postulate that bariatric surgery may lead to an achalasia-like syndrome when there is functional obstruction just distal to the esophagus. Recognition of this potential complication is important to recognize because the most effective therapy for these patients needs to be directed toward the functional abnormality created by the bariatric surgery and not by conventional achalasia therapy such as myotomy.…”

Would you have laparoscopic Nissen fundoplication again? A patient satisfaction survey in a UK population

“…Postoperative negative outcomes are difficult to quantify and predict as ‘failure’ depends on definition used (eg, continued symptoms compared with need for reoperation) and whether using subjective or objective measures (eg, GORD symptoms vs endoscopically proven oesophagitis). Furthermore, previous studies have shown that postoperative reflux symptoms do not necessary correlate with objective reflux, and so do not always reflect technical success of the operation 5 6. These factors combined make the preoperative discussion difficult for both clinician and patient, as it means weighing-up the odds of improvement in a symptom that a patient currently finds distressing with an (often subjective) outcome that the patient has not experienced before (eg, dysphagia or bloating), which also does not reflect on the technical success of the operation.…”

“…With LNF, the desired aim is ultimately an improvement in quality of life (in this case through decreased reflux symptoms and medication use). Objective outcomes such as oesophageal pH, manometry and medication requirement are repeatable measures that can assess the technical success of the procedure but do not necessarily assess (or represent) the extent of symptoms that patients are experiencing since the surgery or the impact that it has on their lives 5 6. Similarly, one must not underestimate the importance of different patients’ experiences during their journey through surgery, and how it may influence their perception of the whole process.…”