Esophageal function after paraoesophageal hernia repair: manometric and symptomatic outcomes

Symptoms of dysphagia and chest pain in large paraoesophageal hernias (POH) can mimic disorders of esophageal motility. High-resolution manometry (HRM) is the gold standard for assessing esophageal motility, however limited data exist in the settings of giant POH. Technical failure of HRM has been historically frequent due to the difficulty of negotiating the cardio-esophageal junction. Prospectively populated database containing records of patients undergoing POH repair was analyzed for the period between 2019 and 2024. Inclusion criteria were the presence of a large POH, pre-operative HRM, and post-operative HRM. Primary outcomes were HRM success rate and manometric changes before and after surgery. Secondary outcomes were patient-reported heartburn, regurgitation, and dysphagia. Multivariate analysis assessed correlations between symptoms and manometric findings. Preoperative HRM was attempted in 71 and succeeded in 64 (90.1%) patients of whom 41 completed post-operative HRM. Mean age was 72.5 years, 85% female. Esophagogastric junction contractile integral (EGJ-CI) increased from 33.3 to 41.9 mmHg/cm (P = 0.018), with no significant changes in integrated relaxation pressure, distal contractile integral, or proximal contractile integral; EGJ morphology normalized in most patients. Ineffective esophageal motility was present in 22% preoperatively and 19.5% post-operatively. Symptoms improved significantly: heartburn (P < 0.01), regurgitation (P = 0.03), and dysphagia (P = 0.01). HRM was feasible in most patients with large POH. Surgical repair led to significant symptom improvement and normalization of EGJ morphology, despite minimal changes in peristaltic measures. These findings suggest that symptom improvement may occur independently of measurable motility criteria.