Esophageal function studies in the management of gastroesophageal reflux disease

Esophageal function testing, i.e. esophageal manometry and 24-h pH monitoring, are usually carried out to diagnose gastroesophageal reflux disease (GERD) in patients with atypical symptoms, when there is no evidence of esophagitis at endoscopy, or following previous unsuccessful surgery. Additionally, these studies should be considered mandatory before surgery to confirm the diagnosis and to tailor the procedure to the motility pattern of the individual patient.

The aim of this study was to assess the role of esophageal function studies in the management of patients with GERD.

Patients with a mechanically defective lower esophageal sphincter (LES) and abnormal esophageal acid exposure proven at 24-h pH monitoring were considered for surgery. A 360 degrees fundoplication (Nissen) was performed in patients with good esophageal motility, whereas a partial 180 degrees fundoplication (Toupet) in patients with a defective motility. Five hundred and eighty-six patients were referred to our laboratory for symptoms suggestive of GERD between November 1992 and April 1999.

Twenty-four hour esophageal pH monitoring was positive in 65.5% of these patients; manometry showed a defective lower esophageal sphincter and a defective esophageal body motility in 57.8% and 21.7% respectively. One hundred and two patients underwent a total fundoplication, and 43 patients a partial wrap. At a mean follow-up of 36 months (range 5-69) the actuarial success rate in the control of reflux was 90%. Three (2.9%) patients undergoing a Nissen fundoplication complained of persistent dysphagia; two of them had preoperative esophageal body dysfunction.

Esophageal function studies allow proper selection of patients for surgery and guide in the choice of the antireflux operation.