Intraoperative manometry to assess the esophagogastric junction during laparoscopic fundoplication and myotomy

Surgery for gastroesophageal reflux disease and achalasia is performed to a lleviate symptoms by improving esophagogastric junction (EGJ) function. Int raoperative manometry was used to evaluate the pressure-length characterist ics of the reconstructed EGJ during laparoscopic Nissen fundoplication and laparoscopic Heller myotomy. Intraoperative manometry was performed in 37 c onsecutive patients undergoing laparoscopic Nissen fundoplication (n=22) or laparoscopic Heller myotomy (n=15). Measurements were taken before surgery , after creation of the pneumoperitoneum, after completion of the myotomy i n achalasia, and after creation of the fundoplication. Tracings were analyz ed for pressure, length, and the integrated pressure-length relation (area under the curve [AUC]). Statistical comparison was made using paired t test s; intraoperative EGJ measurements did not correlate well with preoperative values for either pressure or length. Laparoscopic Nissen fundoplication s ignificantly increased pressure, length, and AUC of the EGJ compared with p refundoplication values. Laparoscopic Heller myotomy significantly decrease d EGJ pressure, length, and AUC. Creation of a Toupet fundoplication after myotomy did not significantly increase pressure, length, and AUC of the EGJ compared with postmyotomy values. Intraoperative manometry identified 2 of 15 achalasia patients (13%) with persistent areas of high pressure after i nitial myotomy that were corrected by extending the myotomy. Intraoperative manometry identifies mechanical changes created during EGJ surgery and may be a useful adjunct to improve outcomes of laparoscopic Nissen fundoplicat ion and laparoscopic Heller myotomy.