A prospective study of the value of preoperative oesophageal manometry in selecting patients for gastro-oesophageal reflux surgery has been performed. One hundred and twenty-six consecutive patients had a floppy Nissen fundoplication with a median follow-up period of 48 months (range 21-96 months). Reflux was controlled in 116 patients (92.1 per cent). One hundred and five patients (83.3 per cent) had a clinically satisfactory result (Visick grades 1 and 2). Poor results were largely due to recurrent reflux, technical failure or the irritable bowel syndrome. An unsatisfactory result was not more likely in those with upright reflux, an oesophageal motility disorder or a competent cardia as defined by manometry. Preoperative oesophageal studies, other than those required to make an accurate diagnosis, were found to have no value in deciding the suitability of patients for surgical correction of gastro-oesophageal reflux.

Recurrent reflux and wrap disruption after Nissen fundoplication: detection, incidence and timingOne hundred and twenty-five patients with refractory gastrooesophageal reflux disease underwent floppy Nissen fundoplication. Median follow-up was 52 months, and included endoscopy, manometry and prolonged p H recordings in all cases in addition to clinical assessment. Using objective criteria, 12 patients (9.6 per cent) developed recurrent reflux. In nine of these patients, endoscopy had suggested that the Nissen fundoplication had disrupted; wrap disruption was confirmed in seven patients who underwent reoperation. The median time to endoscopic recognition of wrap disruption was 7 months (range 3-10 months). In contrast, of 115 patients with endoscopic evidence of an intact fundoplication, only 3 (2-6 per cent) had recurrent reflux. Endoscopy allowed reliable differentiation between those with and without reflux control after operation ( P < 0.001). These results suggest that recurrent reflux after Nissen fundoplication is due to wrap disruption. This phenomenon occurs within the first postoperative year and can be recognized by informed endoscopic assessment.

SUMMARY Computer analysed transit of a liquid bolus containing Tc99m (RT) was compared with manometry for the detection of oesophageal motility disorders in 151 patients with a variety of oesophageal symptoms. Manometry was abnormal in 99 of whom 44 had abnormal RT (sensitivity 44%); it was normal in 52 of whom 37 had normal RT (specificity 71%). The commonest manometric abnormalities were non-specific motility disorders characterised by abnormalities of peristaltic amplitude, waveform or baseline. Radionuclide transit was abnormal in only 32/77 (42%) of these. Achalasia, which is characterised by complete aperistalsis, was the least common diagnosis, but all five cases had abnormal RT. Simultaneous manometry and RT in 30 patients showed that the transit of a liquid bolus through the oesophagus is determined by the propagation rather than the form of the peristaltic contraction. Because non-specific motility disorders are common in clinical practice, RT is not a useful screening test for oesophageal dysmotility.Oesophageal motility disorders are common causes of dysphagia and chest pain.' In most cases oesophageal manometry is required for diagnosis and it has also been suggested that manometry should be done before antireflux surgery to exclude motility disorders which might lead to troublesome dysphagia after fundoplication.2 3 Manometry is uncomfortable, however, and requires considerable experience and expertise in its performance and interpretation.Computer analysed liquid bolus transit of 99mTechnetium is a rapid, simple and non-invasive test which has been reported to be highly sensitive for the detection of oesophageal dysmotility.4 5 Radionuclide transit (RT) measurement also has the advantage that it can be done in any hospital using standard gamma camera equipment with minimal modification.To date, however, the usefulness of RT has only been studied in small groups of patients,4 5 and there has been only one study which has looked at the exact relationship between peristaltic pressures and bolus transit.6 The present study was undertaken to determine this relationship and to assess prospectively the diagnostic value of RT in an unselected group of patients referred for oesophageal function studies.