j gastrointest surg 2012_highres_manometry
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ORIGINAL ARTICLE
High-Resolution Manometry Patterns of Lower
Esophageal Sphincter Complex in Symptomatic
Post-Fundoplication Patients
Masato Hoshino & Ananth Srinivasan & Sumeet K. Mittal
Received: 4 November 2011 /Accepted: 14 December 2011 /Published online: 10 January 2012# 2012 The Society for Surgery of the Alimentary Tract
Abstract
Introduction There has been an increase in the number of patients seeking treatment after an anti-reflux surgical procedure.
The objective of this study is to describe high-resolution manometry (HRM) topography as it relates to the post-
fundoplication anatomy.
Methods Retrospective review of a prospectively maintained database was conducted to identify patients who underwent
esophagogastroduodenoscopy and HRM at Creighton University Medical Center (CUMC) between November 2008 and
October 2010, for symptoms after a previous fundoplication. Patients were categorized as having intact, intrathoracic,
disruptured, twisted, or slipped fundoplication based on endoscopic findings.
Results Sixty-one patients {intact, 17(28%), disrupted, 2(3%), twisted, 3(5%), intra-thoracic, 18(30%), slipped, 21(34%)}
are included in this study. A double high-pressure zone (HPZ) configuration was identified in both intra-thoracic and
slipped fundoplication. This was not noted in appropriately positioned fundoplications. In intra-thoracic fundoplications,
the HPZ below the fundoplication was lower pressure and showed respiratory variations. In slipped fundoplication, the
higher HPZ had lower pressure and no respiratory variations. In appropriately positioned fundoplication, the lower
esophageal sphincter (LES) pressure and extent of relaxation in the single HPZ correlated with intact (normal pressure
and good relaxation), disrupted (low pressure and good relaxation), and twisted (high pressure with incomplete
relaxation) fundoplication. Patients with only a recurrent para-esophageal hernia had characteristics of an appropriately
positioned fundoplication.
Conclusion LES complex HRM findings correlate well with anatomical status of the fundoplication.
Keywords High-resolution manometry (HRM) .
Fundoplication . Lower esophageal sphincter (LES)
Introduction
Anti-reflux surgery (ARS) for refractory gastro-esophageal
reflux disease (GERD) has satisfactory long-term outcome
in greater than 90% of patients.1 – 3 Remaining patients report
either recurrence of symptoms or development of undesirable
side-ef f ects and a subset of these patients require re-operative
ARS.4 – 11 Comprehensive evaluation including upper endos-
copy, contrast study, manometery, selective 24 h pH study,
and gastric emptying study may be done prior to re-operative
intervention.11 Assessment of fundoplication competence and
the association of various anatomic distortions with patient ’s
symptoms are important.12
Advent of high-resolution manometry (HRM) has allowed
for improved diagnostic assessment of esophageal function.
Abstract presented at the American College of Surgeons 97th AnnualClinical Congress, Surgical Forum, San Francisco, CA, October 2011.
M. Hoshino : A. Srinivasan : S. K. Mittal (*)Department of Surgery, Creighton University Medical Center,601, North 30th Street, Suite 3700,Omaha, NE 68131, USAe-mail: skmittal@creighton.edu
S. K. MittalDepartment of Surgical Gastroenterology and Liver Transplant,Sir Ganga Ram Hospital,Delhi, India
J Gastrointest Surg (2012) 16:705 – 714
DOI 10.1007/s11605-011-1803-4
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The color-coded display of the pressure topography offers
increased ease of interpretation and detection of hiatus hernia
when compared to conventional manometery.13 – 16 HRM has
replaced conventional manometry as the gold standard for
assessing esophageal function. There are multiple channels
in close proximity along the length of the catheter and traverse
the lower esophageal sphincter (LES), the esophageal body,
and the upper esophageal sphincter (UES) simultaneously.This allows for shorter procedure times as well as compen-
sates for any swallow associated movement of the catheter.
The pressure changes across the length of the esophagus are
displayed as a color contour plot format which makes inter-
pretation easier and more intuitive. A new classification based
on HRM has been proposed and widely accepted.13,14
The fundoplication alters LES and crus configuration.
The intrinsic LES and extrinsic crus compression along with
pressure effects of the fundoplication determine the distal
esophageal high pressure zone (HPZ) pressure topography.
Simultaneous interplay of these factors determines the com-
petence of the sphincter (to prevent reflux) and its compli-
ance (to allow passage of the food bolus). There is paucity
of literature pertaining to HRM pressure topography of the
distal esophageal HPZ after an ARS. The objective of this
study is to evaluate HRM distal esophageal HPZ and LES
parameters in post-fundoplication patients with different
(endoscopic) patterns of failure.
Material and Methods
All patients undergoing esophageal function testing at the
esophageal center at Creighton University Medical Center
are entered in a prospectively maintained database. The labo-
ratory, first established in 1984, has served as a tertiary referral
center for diagnostic evaluation. Since 2008, we have includ-
ed HRM in our armamentarium. After institutional review
board approval, the database was queried to identify patients
who underwent HRM at the esophageal center after a previous
fundoplication. Patients till October 2010 are included in the
study. To clearly associate HRM distal esophageal HPZ pat-
terns in various types of failures only patients who underwent
endoscopy (within 1 week of manometery) by the senior
author (SKM) are included in this study. Patients completed
a standardized symptom questionnaire administered by the
esophageal laboratory nurse prior to testing. This included
symptoms: heartburn, regurgitation, dysphagia, and chest pain
(Appendix A) on a scale of 0 – 3. The patients with grade 2 and
3 were considered to have significant symptom.
Endoscopy
Upper endoscopy was performed in the left lateral decubitus
position under conscious sedation. Detailed assessment of
the fundoplication was done as described by our group
elsewhere.12 A note was made of the location of the
gastro-esophageal junction (GEJ) in relation to the fundo-
plication and the crus, competence, and symmetry of the
fundoplication and the spatial orientation of the fundoplica-
tion with the crus. The endoscopic terms used to describe
the fundoplication changes are: (1) intact fundoplication, (2)
disrupted fundoplication, (3) twisted fundoplication, (4)intra-thoracic fundoplication, and (5) slipped fundoplica-
tion. Twisted fundoplication is not a universal term. The
anterior and posterior fundoplication tucks are asymmetri-
cal, with one deeper and more twisted in appearance than
the other fundoplication tuck. Detailed endoscopic descrip-
tion of these has been given previously by our group.12
High-Resolution Manometry
Combined high-resolution solid state manometry and im-
pedance manometry catheter (Sandhill Scientific Inc., High-
land Ranch, CO, USA) was used. For the purpose of this
study, impedance tracings were not evaluated. The catheter
has 32 solid state pressure sensors placed 1 cm apart and
five dual impedance sensors 5 cm apart. The manometry
study was performed after trans-nasal positioning of the
catheter and in supine position. The distal esophageal HPZ
was identified, and the catheter was positioned such that two
sensors were below the LES to measure the gastric pressure.
Esophageal baseline pressure and pressure in the HPZ in the
distal esophagus were recorded. Esophageal body function
was assessed with ten liquid swallows (5 cc) and ten viscous
swallows (5 cc). During respiratory cycle, normal variation
is noted in luminal pressure, the pressure wave within the
thoracic esophagus is opposite to than within the abdominal
esophagus/stomach. The respiratory inversion point (RIP) is
where the respiratory variation changes from an abdominal
to thoracic pattern, and this marks the proximal limit of the
abdominal segment of the LES. The proximal border of the
LES is the channel at which the pressure falls below the
esophageal baseline. The pressure topography was analyzed
using the Bio View Analysis software (Sandhill Scientific
Inc., Highland Ranch, CO, USA).
Chicago classification13,14 was incorporated into Bio
View analysis soft ware (version M) (Sandhill Scientific
Inc., Highlands Ranch, CO, USA) in October 2010. All
studies were reanalyzed using updated software for this
study. The basal LES pressure was calculated without any
swallows as the pressure within the LES complex. The
abdominal length (AL) and total length (TL) of the LES
was calculated using tracing mode. AL is the distance be-
tween the distal border of the LES and the RIP. TL is the
distance between the distal and proximal borders of the
LES. The adequacy of LES relaxation was assessed by
calculating the integrated relaxation pressure (IRP). IRP is
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the mean of lowest relaxation pressures measured within the
LES for a minimum of 4 s during a swallow. Esophageal
body function was assessed by distal contraction integral
(DCI). DCI is a parameter that integrates the length (centi-
meter), contractile pressure (mmHg), and duration (second)
of contraction.
Representative HRM pressure topography without
previous fundoplication is shown in Fig. 1a , b.
Without Hiatus Hernia Figure 1a shows HRM pressure
topography in a healthy volunteer without a history of
fundoplication. There is a single distal esophageal HPZ with
adequate LES length (AL>1, TL>2 cm) and basal LES
pressure (LESP010 – 35 mmHg) with good relaxation
(IRP<15 mmHg).
With Hiatus Hernia Figure 1b shows a classical double HPZ
seen in with hiatus hernia. The distal HPZ represents the
crus which shows significant respiratory variation while the
proximal HPZ represents with native LES which shows
deglutitive relaxation.
24 h pH Study
This was performed using either a catheter-based system
(Digitrapper 400pH®; Medtronic, Minneapolis, MN) or a
capsule-based system (Bravo®; Medtronic, Minneapolis,
MN). The pH probe was passed trans-nasally and positioned
5 cm above the upper border of the manometrically defined
LES while the capsule was passed trans-orally and posi-
tioned 6 cm above the endoscopic gastro-esophageal junc-
tion. For the capsule based system, the pH<4 fraction time
was the mean of the scores over 2 days. A positive pH study
was one where the total time pH<4 for >4.2% of the study
time.
Statistical Analysis
Medians with interquartile ranges (IQR) are expressed for
continuous variables. Chi-square test was used to compare
categorical variables. Kruskal – Wallis test and Mann –
Whitney’s U test were used to compare continuous variables.
A p value<0.05 was considered significant. SPSS version 17
(SPSS, Inc, Chicago, IL, USA) was used for all statistical
analysis.
Results
During the study period, 331 patients underwent HRM at
the esophageal center. After excluding 250 patients without
history of fundoplication and 20 patients without esophago-
gastroduodenoscopy [(EGD) within 7 days] 61 patients met
inclusion criteria. There were 45 (74%) females and the
median age for the cohort was 58 years (range 25 – 85 years).
Based on endoscopic assessment, there were 17 intact fun-
doplications, 2 disrupted fundoplications, 3 twisted fundo-
plications, 18 intra-thoracic fundoplications (13 patients
IRP Basal LESP
Without hiatushernia(no fundoplication)
With hiatus hernia (no fundoplication)
IRP Basal LESP
Diaphragmatic Hiatus
a
b
Fig. 1 a The HPZ pressuretopography in a healthyvolunteer at 20 mmHg isobariccontour. There is a single distalHPZ comprising of the LES andthe crus. IRP is within normallimits. Basal LES pressure isalso within normal limits. HPZ
high pressure zone, IRP
integrated relaxation pressure, LES lower esophagealsphincter. b The HPZ pattern of a patient with hiatus hernia. Thedistal HPZ represents the regionof the crus with significant
respiratory variations while the proximal HPZ represents thenative LES which showsdeglutitive relaxation. HPZ
high pressure zone, LES lower esophageal sphincter
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with intact, 5 patients with disrupted), and 21 slipped
fundoplications (Table 1).
Table 1 compiles the manometry and 24 h pH study
results with endoscopic findings. Thirty-one patients under-
went 24 h pH study of whom 20 (65%) has a positive score.
Two patients with endoscopically assessed intact infra-
diaphragmatic fundoplication were noted to have a double
HPZ, both these patients also had a positive pH score.When compared with intact, patients with disrupted
intra-thoracic and slipped had lower basal LES pressure
(15.9 vs. 21.8, 16.3 vs. 21.8, both p<0.05), patients with
twisted had higher IRP (37.0 vs. 22.0, p <0.05). There was
no difference in DCI. A double HPZ configuration could
be clearly identified in 12/18 (67%) intra-thoracic fundo-
plications (9/13 intact and 3/5 disrupted) and 16/21 (75%)
slipped fundoplications. In remaining patients, probably
the spatial separation of the native GEJ, the fundoplication
and the crus is not sufficiently large enough to clearly
allow distinct identification of double HPZ. There was no
apparent symptom difference between the patients with
and without double HPZ within each group (intra-thoracic
and slipped). Across the spectrum of anatomic configura-
tions, there was good agreement between manometry find-
ings and endoscopic assessment.
There was no significant difference in reported symptoms
in the sub-categories. Ten patients with intact fundoplication
had a high IRP, of these, 8 patients (80%) reported dysphagia.On the other hand, 3 (43%) patients with normal IRP also
reported dysphagia.
Corresponding distal esophageal HRM pressure topogra-
phy could be identified for each of these anatomical config-
urations (Fig. 2a – f ). Of these, three patients also had pressure
topography consistent with an aperistaltic body (Fig. 2g).
1. Intact fundoplication (Fig. 2a ): In patients with intact
fundoplication, there is a single distal HPZ. The LES
configuration is slightly longer (AL03 and TL05 cm)
and with higher LES pressure (28.9 mmHg) than
Table 1 Individual descriptions of sub-categories, with respect to demographic variables
Intact (17) Disrupted
(2)
Twisted
(3)
Intact intra-thoracic
(13)
Disrupted intra-thoracic
(5)
Slipped (21) p value
Symptoms (n061)
Heartburn 9 (53%) 1 (50%) 1 (33%) 8 (62%) 3 (60%) 11 (52%) 0.968
Regurgitation 9 (53%) 2 (100%) 1 (33%) 7 (54%) 4 (80%) 16 (76%) 0.332
Dysphagia 11 (65%) 1 (50%) 2 (67%) 6 (46%) 1 (20%) 10 (48%) 0.591
Chest pain 7 (41%) 1 (50%) 2 (67%) 4 (31%) 1 (20%) 11 (52%) 0.642
LES and body contraction findings on HRM (n061)
Basal LES pressure (mmHg) 21.8 (17.6 – 35.4)d, e 11.8 (NA) 39.8 (NA) 20.1 (10.4 – 22.9) 15.9 ( 6.7 – 19.5) 16.3 (10.3 – 21.2) 0.028
Low basal LES pressure(<10 mmHg)
0/17 1/2 0/3 3/13 1/5 5/21 0.229
High basal LES pressure
(>35 mmHg)
4/17 b 0/2 3/3 1/13 0/5 3/21 0.005
IRP (mmHg) 22.0 (11.2 – 27.1) b 7.5 (NA) 37.0 (NA) 20.2 (7.5 – 36.4 ) 1 2.7 (4.7 – 14.1) 23.0 (14.0 – 28.7) 0.038
High I RP ( >15 m mHg) 10/17d 0/2 3/3 7/13 0/5 16/21 0.011
Double HPZ (n031) 2/17a, c, d, e ½ 0/3 9/13 3/5 16/21 0.001
DC I ( mmHg- s- cm) 35 64 ( 2,29 9 – 6,633) 517 (NA) 4631 (NA) 2575 (1,574 – 3,833) 2,127 (2,033 – 6,531) 3,141 (2,539 – 6,471) 0.149
24 h pH study findings (n031)
Fr ac tion time pH > 4.0 0.2 ( 0 – 5.5)d, e 6 .0 ( NA) 0 (N A) 6.1 ( 4.1 – 18.5) 21.8 (NA) 14.9 (3.1 – 29.6) 0.017
Positive pH (>4.2%) 3/9 1/1 0/1 3/4 3/3 10/13 0.113
Surgical procedure (n030)
Redo fundoplication (n012) 1/17 0/2 0/3 3/13 2/5 6/21 0.334
RNY (n018) 1/17 1/2 1/3 5/13 1/5 9/21 0.186
Values expressed as median (IQR)
LES lower esophageal sphincter, IRP integrated relaxation pressure, HPZ high pressure zone, DCI distal contractile integral, RNY Roux-en-Yreconstruction, NA not availablea Two patients with positive pH had dual HPZ indicating abnormal post-fundoplication physiology although the EGD showed an infra-diaphragmatic fundoplication b Intact vs. twisted p<0.05c Intact vs. intact intra-thoracic p<0.05d Intact vs. disrupted intra-thoracic p<0.05e Intact vs. slipped p<0.05
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healthy volunteers. There is adequate relaxation (IRP<
15 mmHg) and the distal esophageal swallow as normal
contour and wave progression.
2. Disrupted fundoplication (Fig. 2b ): In a patient with
disrupted fundoplication, there is a single distal HPZ.
However, there is decreased basal LES pressure
IRP Basal LESP
Twisted fundoplication
IRP Basal LESP
Intact fundoplication
IRP Basal LESP
Disruptedfundoplication
F ig. 2 a The HRM pressure topography of a patient with intact fundoplication. Compared to a healthy volunteer, the basal LES pres-sure is higher, but there is good LES relaxation during deglutition asthe IRP is within normal limits. LES lower esophageal sphincter, IR P
integrated relaxation pressure. Endoscopic picture reprinted from [12].b Disrupted fundoplication. There is good relaxation with deglutition;however, the basal LES pressure is lower than in an intact fundoplica-tion. LES lower esophageal sphincter. c The HPZ pressure pattern of a patient with a twisted fundoplication is shown in Fig. 2c. One can seethe high basal LES pressure and a lack of deglutitive relaxation asshown by a high IRP. Additionally, one can see high contractions and pressures in distal esophagus with high DCI and is indicative of outflow obstruction. These patients usually present with dysphagia or
chest pain rather than reflux symptoms. LES lower esophageal sphinc-ter, IRP integrated relaxation pressure, DCI distal contractile integral. d
The HPZ pressure topography of an intact intra-thoracic fundoplica-tion. In this patient, the HPZ is split into two: the distal HPZ representsthe crus as the pattern indicates. The fundoplication is represented bythe proximal HPZ. There is adequate pressure in the fundoplicationwith good relaxation as measured by a normal IRP. Such patientsusually present with post-prandial chest/epigastric discomfort due to
distention of the herniated stomach. HPZ high pressure zone, IRP
integrated relaxation pressure. e HRZ patterns in a patient with dis-rupted intra-thoracic fundoplication. The distal HPZ represents thecrus. The proximal HPZ represents the area of the disrupted fundopli-cation. The basal LES pressure is low and there is a normal IRP. Thelow LES pressure indicates a disrupted fundoplication. HPZ high pressure zone, IRP integrated relaxation pressure, L ES lower esopha-geal sphincter. Endoscopic picture reprinted from [12], with permissionfrom Springer. f The HRZ patterns in a patient with slipped fundopli-cation. The proximal HPZ is the native LES and has low basal LES pressure with complete relaxation (normal IRP). The fundoplication isat the level of the crus. The diaphragmatic HPZ overlaps the fundopli-cation. As a result, there is no deglutitive relaxation of the fundoplica-
tion. HPZ high pressure zone, LES lower esophageal sphincter, I R P integrated relaxation pressure. Endoscopic pictures reprinted from [12],with permission from Springer. g Secondary achalasia is shown inFig. 2g. These patients have aperistaltic esophageal body contractions.There is only a single HPZ pressure topography, but the LES pressureand the IRP are high. HPZ high pressure zone, LES lower esophagealsphincter, IRP integrated relaxation pressure
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(4.7 mmHg) and a somewhat shorter length of the
LES (AL01 and TL02 cm) compared to intact fun-
doplication and healthy volunteers. There is adequate
relaxation (normal IRP).
3. Twisted fundoplication (Fig. 2c ): Patients with twisted
fundoplication also have a single distal HPZ. There is
generally a high LES pressure along with impaired
deglutitive relaxation (high IRP). Additionally, the distal
esophageal body contractions show a high contractile
vigor indicating outflow obstruction.
4. Intra-thoracic fundoplication (Fig. 2d, e ): There is a
distinct double-hump configuration in the distal esoph-
agus. The distal HPZ represents the crus and shows
exacerbated respiratory variations. The proximal HPZ
is the fundoplication around the native LES. Depending
on the competency of the fundoplication, there is
Diaphragmatic Hiatus
Basal LESP
Intact intra-thoracic fundoplication
Diaphragmatic Hiatus
Basal LESP
Disrupted intra-thoracic fundoplication
Basal LESP
Fundoplication
Slipped fundoplication
Secondary achalasia
IRP Basal LESP
Aperistaltic body contraction
Fig. 2 (continued)
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adequate (Fig. 2d) or inadequate (Fig. 2e) basal LES
pressure. There is adequate relaxation as observed from
normal IRP.
5. Slipped fundoplication (Fig. 2f ): In patients with
slipped fundoplication, there is also a double hump
configuration. The native LES is the proximal HPZ. In
these patients, the fundoplication is slipped onto the
stomach and is at the level of the crus and is represented by the distal HPZ. In contrast to the intra-thoracic
fundoplication, the distal HPZ does not show the either
exacerbated respiratory variations nor a deglutitive
relaxation. The proximal HPZ shows deglutitive
relaxation.
6. Secondary/missed achalasia (Fig. 2g ): Three patients
had an aperistaltic esophageal body. These could be
either missed achalasia or post-fundoplication achalasia.
All three patients either had an intact or a twisted
fundoplication.
Discussion
HRM has given a clearer understanding of the relationship
between the LES and the crus and their interplay in main-
taining sphincter competence. A double hump distal esoph-
ageal HPZ configuration is consistent with a structurally
defective hiatus.15,16 Tatum et al.17 described HRM manom-
etry findings in post-fundoplication patients and found that a
double hump configuration and low LES pressure correlates
with abnormal distal esophageal acid exposure. In the pres-
ent study, we have demonstrated that different anatomical
configurations of a failed fundoplication have distinct HRM
patterns. This may help better understand mechanisms of
failure.
There has been a dramatic increase in number of
patients undergoing re-operative intervention after previ-
ous ARS.9,10 Detailed anatomical and physiological as-
sessment with in depth understanding of mechanism of
failure is essential prior to redo-ARS. Jobe et al.18 de-
scribed endoscopic assessment of different normal fundo-
plication configurations. Endoscopic configuration of
post-fundoplication anatomy indicates type and cause of
failure.11 On the other hand, Gopal et al.19 concluded
that endoscopic ultrasoundscopy (EUS) gives detailed
anatomic relationship between fundoplication and hiatus.
EUS may enable a precise determination of the anatomic
causes of failure after ARS; however, availability of
equipment and expertise is limited.
HRM allows for in depth assessment of the distal
esophageal HPZ and is able to pick up variations which
were not discernable with conventional manometry. An
appropriately positioned fundoplication lies around the
native LES and is below the crus. This is represented by
a single HPZ. The dual HPZ indicates spatial separation
of this complex and implies failure. HRM allows to fur-
ther distinguish between different types of failures, i.e.,
whether the fundoplication has slipped on to the stomach
and the GEJ has migrated into the chest (slipped fundo-
plication) or that the entire GEJ/fundoplication complex
has migrated into the chest through a lax hiatus (intra-
thoracic fundoplication). Patients deemed to have a dis-rupted fundoplication on endoscopic assessment had
shorter HPZ length and decreased baseline pressure.
Patients with twisted fundoplication have a high LES
pressure and a high IRP implying incomplete relaxation.
Lack of significant symptom correlation with HRM and
24 h pH study results was most likely due to the small
sample size. Two patients with endoscopically assessed
intact infra-diaphragmatic fundoplication were noted to
have a dual HPZ. This leads us to believe that maybe
the fundoplication could be telescoping into the chest
intermittently. Interestingly, both these patients also had
a positive 24 h pH study. HRM could be potentially most
useful in assessing the symptomatic post-fundoplication
patients with an endoscopically intact (seemingly)
fundoplication, probably a more rigid determination of
“intact wrap” using the 10 point criteria laid out by
Jobe et al.18
There are several limitations of this study. Foremost
being that all evaluated subjects are patients with post-
fundoplication complaints and as such there are no con-
trols of asymptomatic post-fundoplication patients. We are
in the process of performing HRM and endoscopic assess-
ment in a cohort of asymptomatic post-fundoplication
patients so that normal length, pressure, and residual pres-
sure values can be calculated. This study had a small
sample size, therefore statistical power is low and type 2
error cannot be ruled out. Another limitation is the lack of
symptom association. However, there is good correlation
with objective reflux testing.
The primary objective of this study was to identify var-
ious HRM findings associated with anatomical failures. This
will allow further work in understanding mechanisms of
failure and assessing symptoms association, especially in
the symptomatic post-fundoplication patients with a seem-
ingly (endoscopic) intact fundoplication.
Conclusion
Distal esophageal HPZ – HRM findings correlate well with
anatomical status of the fundoplication. The introduction
of HRM findings for failed fundoplication may be help-
ful for assessment of symptomatic patient prior to re-
intervention. Further study is needed to understand symptom
correlation.
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Author Disclosure Drs. Masato Hoshino, Ananth Srinivasan, andSumeet K. Mittal have no conflicts of interest or financial ties todisclose.
Appendix
Post-Procedure Questionnaire
Name ____________________________ Date of follow-up __________________________
DOB ____________________________ Sex __________ Data sheet # ___________
Phone number ____________________ Duration since surgery _____________________
Procedure ________________________ Date of procedure _________________________
HEARTBURN
________ times a day/week/month
0 – None
1 – Minimal – episodic, no treatment is required
2 – Moderate – controlled with medication
3 – Severe - interferes with daily activity or not controlled with medication
DYSPHAGIA
0 – None
1 – Once a week or less
2 – More than once a week, requiring dietary adjustment
3 – Severe – preventing ingestion of solid food
REGURGITATION
________ times a day/week/month
0 – None
1 – Mild – after straining of large meal
2 – Moderate – positional
3 – Severe – constant regurgitation with or without aspiration
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CHEST PAIN
________ times a day/week/month
0 – None
1 – Minimal – episodic
2 – Moderate – reason for visit
3 – Severe - interferes with daily activity
NAUSEA / VOMITING
________ times a day/week/month
0 – None
1 – Minimal – episodic
2 – Moderate – reason for visit
3 – Severe - interferes with daily activity
ABDOMINAL BLOATING Yes No
OTHER SYMPTOMS _______________________________________________
MEDICATION
None
Antacids Name _____________ Dose ________ Started by/on __________
H2 blockers Name _____________ Dose ________ Started by/on __________
PPI Name _____________ Dose ________ Started by/on __________
Prokinetics Name _____________ Dose ________ Started by/on __________
WEIGHT _____________
GRADING RATE
How satisfied are you with your surgical outcome? (scale 1-10, 1-worse/10-best) ________
Would you recommend this procedure to a friend? Yes No
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