Predictive value of preoperative esophagram in postoperative outcomes after antireflux surgery

Gastroesophageal reflux disease (GERD) significantly impairs quality of life. Antireflux surgery (ARS) improves symptoms when medical therapy fails, but postoperative recurrence and dysphagia remain concerns, emphasizing the need for improved preoperative risk stratification. This study evaluates whether esophageal transit time (ETT) measured on standard preoperative esophagram can predict postoperative outcomes after ARS and serve as an accessible method to characterize esophageal motility on esophagram and assist in preoperative decision-making.

In this retrospective cohort study, 174 patients underwent Nissen or Toupet fundoplication (± hiatal hernia repair) between 2014-2025 at a tertiary academic center. Patients were required to have preoperative esophagram and ≥ 1 postoperative Health-Related Quality of Life (HRQL) follow-up; 92 patients also had high-resolution manometry. Preoperative esophagrams were independently reviewed by a subspecialized radiologist blinded to clinical outcomes. ETT was correlated with manometric findings and postoperative HRQL scores.

Receiver Operating Characteristic (ROC) analysis identified ETT threshold ≥ 5.375 s as associated with greater long-term symptom burden across all patient-reported outcome domains at 3-5 years (p < 0.05). Longer ETT was associated with more failed contractions and weaker distal esophageal contractions on manometry, and ETT showed sensitivity of 75-83%, specificity of 35-46%, positive predictive value (PPV) of 15-55%, negative predictive value (NPV) of 71-94%, positive likelihood ratio (LR +) (1.22-1.54), and negative likelihood ratio (LR-) (0.37-0.65).

ETT greater than 5.375 s was associated with greater long-term symptom burden across all patient-reported outcome domains. Longer ETT correlated with higher percentages of failed contractions and lower distal esophageal contraction amplitude on manometry supporting physiologic relevance. While specificity is low, high NPV suggests ETT less than 5.375 s may serve as a simple, noninvasive screening to help exclude severe dysmotility and reduce reliance on manometry in selected patients. These findings support using ETT as an adjunctive risk-stratification measure to assist in preoperative decision-making rather than a standalone prognostic test.