Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication☆
Presented at the American College of Surgeons 88th Annual Clinical Congress, San Francisco, CA, October 2002.
Received 8 October 2002; received in revised form 26 February 2003; accepted 30 April 2003.
Abstract
Background
Preoperative esophageal manometry and 24-hour pH monitoring commonly are used in preoperative evaluation of patients undergoing fundoplication. Here we review our experience with the selective preoperative workup of patients undergoing fundoplication to treat gastroesophageal reflux disease.
Study design
A series of 628 consecutive antireflux procedures was reviewed. History and physical examination, upper endoscopy, and upper gastrointestinal videofluoroscopy were obtained preoperatively on all patients; the first 30 patients also underwent esophageal manometry and pH monitoring (routine evaluation group). Thereafter, pH monitoring only was performed for atypical reflux symptoms, and manometry only was performed for a history of dysphagia, odynophagia, or for abnormal motility on videofluoroscopy (selective evaluation group). All patients underwent a laparoscopic floppy Nissen fundoplication, and then endoscopy and fluoroscopy at 3 months and 12 months postoperatively.
Results
Eighty-five of the patients in the selective evaluation group (14%) required manometry, and 88 (15%) underwent pH monitoring. Eighteen of the 115 patients who underwent manometry (16%) had evidence of dysmotility. None of these 18 patients had increased dysphagia postoperatively; 8 of 18 reported improvement with swallowing. Five patients in the selective group (0.8%) had persistent postoperative dysphagia caused by technical error (four patients) or with no identifiable cause (one patient). The estimated charge or collection reduction with use of the selective evaluation was $1,253,100 or $395,000, respectively.
Conclusions
Selective use of manometry and pH monitoring was cost effective and safe in this series. Although esophageal manometry and 24-hour pH monitoring might be necessary with abnormal findings on videofluoroscopy or atypical symptoms, in our experience, their routine use is not essential in preoperative evaluation of patients undergoing fundoplication for gastroesophageal reflux disease.
†Radiology (Smith), Rush University, Chicago, IL, USA
‡Department of Surgery, University of Nebraska Medical Center and the VA Medical Center, Omaha, NE, USA (Carlson)
§Department of Surgery, University of Tennessee-Memphis, Memphis, TN, USA (Madan)
¶Department of Radiology, Medical College of Wisconsin, Milwaukee, WI (Stewart), USA
Correspondence address: Constantine T Frantzides, MD, PhD, FACS, Department of Surgery, Rush University, 1725 West Harrison St, Suite 818, Chicago, IL 60612, USA
ABSTRACT