Evaluation of the Role of Eosaphageal Manometry in Tailoring of Fundoplication Type in the Management of Hiatal Hernia

Introduction: An established surgical treatment for patients with hiatus hernia with gastroesophageal reflux disease
(GERD) is laparoscopic fundoplication. In order to enhance reflux control while reducing negative postoperative
troublesome side effects mainly dysphagia, high resolution esophageal manometry (HRM) is considered an essential
step in preoperative evaluation.
Aim of work: To examine the impact of preoperative high-resolution manometry (HRM) on determining the
appropriate type and degree of fundoplication in patients with hiatus hernia, aiming to anticipate surgical outcomes,
focusing particularly on the probability of postoperative dysphagia. The evaluation includes both a short-term
(3-month) and a long-term (6-month) postoperative follow-up period.
Patients and methods: 24 eligible patients with an established diagnosis of hiatal hernia were the total number
of patients in our prospective clinical trial study at the General Surgery outpatient’s clinic, Ain-Shams University
Hospitals, in the period from April 2022 until the end of October 2022. They were divided intentionally according
to their preoperative high-resolution oesaphageal manometry results into two equal groups; the first 12 patients
with oesophageal hypomotility underwent partial fundoplication. The other 12 having normal oesophageal motility
underwent complete fundoplication. All the patients met the inclusion criteria. Exclusion criteria included: (a)
pregnant and lactating females. (b) patients with a history of previous esophagogastric surgery. (c) Patients with
achalasia. (d) patients who will refuse to participate in the study. (e) surgically unfit patients.
Results: Regarding the difference between follow-up visits after 3 and 6 months among group 1 “partial
fundoplication,” there was no statistically significant difference between them, i.e., no worsening of symptoms,
where the following GERD, bloating, and dysphagia were reported in 0 (0%), 2 (16.7%), and 1 (8.3%), respectively,
of patients at 3 months and in 0 (0%), 1 (8.3%), and 0 (0%) of patients at 6 months. difference between follow-up
visits after 3 and 6 months among group 2 “complete fundoplication,” the following GERD, bloating, and dysphagia
were reported in 0 (0%), 3 (25%), and 3 (25%), respectively, of patients at 3 months and in 0 (0%), 0 (0%),
and 2 (16.7%), respectively, of patients at 6 months.No significant association was demonstrated between other
preoperative HRM parameters and surgical outcomes.
Conclusions: Preoperative esophageal manometry is a crucial step before deciding the type of fundic wrap
fashioned as an antireflux procedure in patients with hiatus hernia. Inadequacy of lower esophageal sphincter
(LES) relaxation with swallowing, indicated by high integrated relaxation pressure (IRP), or weak esophageal
motility as shown by a low distal contractile integral (DCI), are key predictors of adverse long-term postoperative
outcomes most importantly dysphagia.