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The etiology of postfundoplication dysphagia remains incompletely understood. Subtle changes of gastroesophageal junction (GEJ) anatomy may be contributory. Barium swallows have potential for standardization to evaluate postsurgical anatomical features. Using structured barium swallows, we aim to identify reproducible, objectively measured postfundoplication anatomical features that will permit future comparison between patients with/without dysphagia. At 6-12 months of postfundoplication, 31 patients underwent structured barium swallow with video-fluoroscopy recording: standing anteroposterior; standing oblique (×2); prone oblique (×2); and prone oblique with continuous free drinking. A primary observer recorded 11 variables of GEJ anatomy for each view, repeated 3 months later, forming two datasets to assess intraobserver consistency. Interobserver reliability was determined using a dataset each from the primary observer and two medical students (after training). Intraclass correlation coefficients (ICC) were based on two-way mixed-effects model (ICC agreement: 0.40-0.59 'fair'; 0.60-0.74 'good'; 0.75-1.00 'excellent'). Interobserver reliability was good-excellent for 47 of 66 measurements. Measures of maximal esophageal diameter cf. wrap opening diameter and posterior esophageal angle showed high interobserver reproducibility on all views (ICC range 0.84-0.91; 0.68-0.80, respectively). Interobserver agreement was good-excellent for 5/6 views when measuring anterior GEJ displacement and axis deviation (ICC range 0.56-0.79; 0.41-0.77, respectively). Measures of wrap length showed lower reproducibility. Prone oblique measurements showed highest reproducibility (good-excellent agreement in 19/22 measurements). Intraobserver consistency was excellent for 98% of measurements (ICC range 0.74-0.99). Objective measurements of postfundoplication GEJ anatomy using structured barium swallow are reproducible and may allow further interrogation of anatomical features contributing to postfundoplication dysphagia., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Anti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, particularly in individuals with an aperistaltic esophagus (absent esophageal contractility). This study determined the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility., Methods: A prospective database was used to identify all (40) patients with absent esophageal contractility who subsequently underwent fundoplication (36 anterior partial, 4 Nissen). Cases were propensity matched based on age, gender, and fundoplication type with another 708 patients who all had normal motility. Groups were assessed using prospective symptom assessment questionnaires to assess heartburn, dysphagia for solids and liquids, regurgitation, and satisfaction with surgery, and outcomes were compared., Results: Across follow-up to 10 years, no significant differences were found between the two groups for any of the assessed postoperative symptoms. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5- and 10-year follow-up. No differences in overall patient satisfaction were identified across the follow-up period., Conclusion: Laparoscopic partial fundoplication in patients with absent esophageal contractility achieves acceptable symptom control without significantly worse dysphagia compared with patients with normal contractility. Patients with absent contractility should still be considered for surgery., (© 2021. Crown.)

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.

Background: Although laparoscopic cardiomyotomy is considered to be the treatment of choice for achalasia, there is no consensus about how persistent or recurrent dysphagia after myotomy should be treated. In the current study we evaluated our experience with reoperation following previous cardiomyotomy., Methods: Between 1992 and 2006, 19 patients underwent re-myotomy: 7 for persistent dysphagia, 12 for recurrent dysphagia. Different operative approaches were used, depending on surgeon's preference and the technique used for the first operation., Results: The mean interval between the cardiomyotomies was 81 months. In 12 patients, the alternative body cavity to that used for the first operation was used for access in the revision operation. This was associated with a shorter operation time. Mean follow-up after the revision operation was 3.6 years. Mean satisfaction score was 7 (out of 10), and 89% of patients had an improvement in symptoms., Conclusion: Reoperation for persistent or recurrent achalasia achieves a satisfactory outcome in most patients. Using the alternative body cavity to that used in the original procedure facilitates minimal access techniques, and gives easier access to the operative field.

The article discusses research on reporting of stroke care quality in Veterans Health Administration Medical Centers in the U.S. The study involved 3,812 veterans suffering from ischemic stroke admitted to 106 Medical Centers in 2007. It recommends 8 quality indicators (QIs) for performance rating, including dysphagia screening, fall risk assessment and pressure ulcer risk assessment.

Background: A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients.Material and Methods: Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP > or = 30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0-10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group.Results: Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30-55). Median follow-up after fundoplication was 99 (12-182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036).Conclusion: Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate. [ABSTRACT FROM AUTHOR]

Introduction The outcome after laparoscopic Nissen fundoplication can be assessed by either clinical symptoms or objective tests. Outcomes from objective tests are often held in higher regard than clinical data when determining the merits, or otherwise, of various antireflux surgery procedures. In this study, we sought to determine whether there is a relationship between postoperative symptoms and parameters measured by esophageal manometry to determine whether early postoperative esophageal manometry is a useful investigation for the routine assessment of post fundoplication outcome. Methods One hundred and forty-three patients who had undergone a laparoscopic Nissen fundoplication, clinical follow-up at 3 months and 5 years after surgery, and esophageal manometry at 3 months after fundoplication as part of routine followup in 1 of 5 clinical trials were studied. Nineteen of these patients also underwent manometry 5 years after fundoplication. Postoperative symptoms were prospectively determined by applying a standardized questionnaire, which assessed dysphagia, heartburn, bloat symptoms, and overall satisfaction using analog scales. Patients were classified into different groups according to the analog scores for clinical symptoms. Correlations between clinical and postoperative manometry outcomes were sought. Results No significant associations were found between parameters measured by esophageal manometry (lower esophageal sphincter resting and residual relaxation pressures, peristaltic amplitude and normal peristaltic propagation) and clinical parameters (dysphagia, heartburn, bloating, and overall satisfaction) for all time points--3 months postoperative manometry vs symptoms at 3 months and 5 years, 5 years postoperative manometry vs symptoms at 5 years, except for a weak (r=-0.17, p=0.042) correlation between the percentage of successfully propagated swallows at 3 months and dysphagia for solids at 5 years. Conclusion Postoperative esophageal manometry parameters at 3 months and 5 years after surgery were not associated with any clinically important differences in the postoperative symptoms of heartburn, dysphagia, bloat or with overall satisfaction with the surgical outcome. The routine use of esophageal manometry to assess the outcome after Nissen fundoplication does not predict clinical outcome. [ABSTRACT FROM AUTHOR]

Introduction: A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Many of these patients have been empirically recommenced on proton pump inhibitors.Objective: The aim of this study was to determine whether patients with symptoms that suggest recurrent reflux had objective evidence of reflux, and to determine predictors of recurrent reflux.Methods: We identified all patients from an existing database who had undergone pH monitoring for "recurrent heartburn" after fundoplication. These patients were then cross-referenced to another database, which recorded the outcomes for patients who had undergone a laparoscopic fundoplication. Patients complaining of dysphagia or other problems without heartburn were excluded from analysis.Results: Seventy-six patients were identified who met the inclusion criteria. Fifty-six (74%) of these had a normal 24-h pH study. Thirty-five patients (63%) with a normal pH study were on medication for heartburn at the time of referral. Three factors were found to be associated with an abnormal 24-h pH study: a partial fundoplication (P = 0.039), onset of symptoms 6 months or more after surgery (P < 0.001), and a good symptom response when antireflux medication was recommenced (P = 0.015).Conclusions: Not all patients complaining of recurrent heartburn after fundoplication have evidence of abnormal reflux. Objective evidence of abnormal esophageal acid exposure should be confirmed before recommencing antireflux medication. [ABSTRACT FROM AUTHOR]

Background Dysphagia can occur in patients with a small hiatus hernia (HH). Whether this relates to a pressure-flow variation through the esophagus or esophago-gastric junction (EGJ) is unknown. Methods High-resolution impedance manometry (HRIM) performed off therapy in 210 reflux patients and 25 age-matched healthy volunteers, recorded 10 × 5mL saline and likewise viscous bolus swallows. Esophageal pressure flow analysis (PFA) with AIMplot v8.0 was undertaken for valid bolus swallows. HRIM EGJ-subtype and endoscopic + /- fluoroscopic imaging enabled HH diagnosis (2–5 cm, > 5 cm excluded). Dysphagia was scored for difficulty swallowing 9 food types (Dakkak and Bennett; 0 none to 45 severe). ANOVA assessed differences in biomechanics of controls and HH + /- patients and dysphagia (D + , > 10/45). Results To date, findings for 135 patients (74M 61F, BMI 28, 19–41) with 70 HH + positive were compared with the 65 HH- negative and 25 healthy controls (7M 18F, BMI 27, 19–37)—see Table. Pressure-Flow Analysis in patients with regard to hiatus hernia (HH + /-) & dysphagia (D + /-) Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  Pressure-Flow Analysis in patients with regard to hiatus hernia (HH + /-) & dysphagia (D + /-) Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  In HH + there was increased resistance (intrabolus pressure) to bolus flow through the esophagus, while pressure during bolus clearance was lower. Further, a higher impedance ratio suggests less effective esophageal emptying, in addition to reduced EGJ outflow time. HH impairs transport of viscous and liquid swallows, affecting patients with HH + and troublesome dysphagia the most. Conclusion A small hiatus hernia alters biomechanics of bolus transport and hinders esophageal and esophago-gastric junction outflow, more so in patients with both dysphagia and hiatus hernia. These findings may relate to altered longitudinal muscle function associated with a short, flaccid esophagus when a hiatus hernia is present. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "An Interesting case of post-fundoplication dysphagia" by M. Jain in October 2014 issue.