Dysphagia and gastroesophageal junction resistance to flow following partial and total fundoplication

Abstract

BACKGROUND: Esophageal peristalsis and basal gastroesophageal junction (GEJ) pressure correlate poorly with dysphagia. AIM: To determine intraluminal pressures that reflect GEJ function and to determine manometric correlates for dysphagia before and after fundoplication. METHODS: The relationships between maximal intrabolus pressure, residual GEJ relaxation pressure and peak peristaltic pressure for water swallows were determined in normal volunteers and patients with reflux disease before and after fundoplication. GEJ anatomy was assessed by radiological, endoscopic and surgical criteria, whilst dysphagia was measured with a validated composite dysphagia score. RESULTS: Dysphagia was significantly associated with lower peak peristaltic pressure in the distal esophagus and the presence of a hiatus hernia preoperatively, as well as higher residual pressure on GEJ relaxation postoperatively. Peak distal peristaltic pressure and residual GEJ relaxation pressure were predictors of intrabolus pressure after total fundoplication (p<0.002). Residual GEJ relaxation pressure was four times higher after 360° fundoplication (N=19) compared to 90° fundoplication (N=14, p< 0.0001). Similarly, intrabolus pressure was elevated 2.5 times after 360° fundoplication and nearly doubled after 90° fundoplication and both were significantly different from controls (N=22) and reflux disease patients (N=53, p<0.0001). CONCLUSIONS: Gastroesophageal junction impedance to flow imposed by fundoplication is associated with dysphagia when there is suboptimal distal esophageal contraction strength and relatively high residual GEJ relaxation pressure.