The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery

Abstract

Background When multiple swallows are rapidly administered, esophageal peristalsis is inhibited, and pronounced lower esophageal sphincter relaxation ensues. After the last swallow of the series, a robust contraction sequence results. The authors hypothesize that multiple rapid swallows (MRS) may have value in predicting esophageal transit symptoms in patients undergoing laparoscopic antireflux surgery (LARS). Methods Records of patients undergoing esophageal high-resolution manometry (HRM) before LARS were evaluated. The evaluation of MRS included adequate inhibitory response during swallows and the contraction pattern after MRS. Dysphagia was scored based on a product of symptom frequency and severity using 5-point Likert scales. A composite dysphagia score comprised the sum of scores for solid and liquid dysphagia, and a score of 4 or higher was considered clinically significant. The normal and abnormal MRS responses of patients with preoperative, early, and late postoperative dysphagia were compared with those of patients with no dysphagia. Results In this study, 63 patients (mean age, 60.3 ± 1.7 years, 48 women) undergoing HRM before LARS successfully performed MRS (median, 5 swallows; longest interval between swallows, 3.2 ± 0.1 s). After MRS, 14 patients (22.2 %) had an intact peristaltic sequence. Complete failure of peristalsis was seen in 21 (33.3 %), and incomplete esophageal inhibition in 25 (39.7 %) of the remaining patients. When stratified by presence or absence of dysphagia, 58.3 % of the subjects without dysphagia had a normal MRS response, whereas 83.3 % had formation of peristaltic segments after MRS. In contrast, only 14 % of the subjects with dysphagia had a normal MRS response (p ≤ 0.003 vs. the subjects with no dysphagia). Abnormal MRS responses were more prevalent in the patients with any preoperative and late postoperative dysphagia (p = 0.04 across groups) and in those with clinically significant dysphagia (p = 0.08 across groups). Conclusions High-resolution manometry with MRS helps to predict dysphagia in subjects undergoing preoperative esophageal function testing before LARS.

Vigor of peristalsis during multiple rapid swallows is inversely correlated with acid exposure time in patients with NERD

“…It is worth noting that all patients had complete inhibition of esophageal body motility during MRS. Similarly, Stoikes et al 18 observed that the inhibition phase during MRS remained intact both in the esophageal body and in the LES in patients with suboptimal DCI and late postoperative dysphagia, suggesting that the contractile defect is not within the inhibitory pathways. Data from this study showed that MRS DCI and MRS/ WS ratio were inversely correlated with AET, but directly correlated with BI values and PSPW index.…”

Oesophageal dysphagia: manifestations and diagnosis

“…50 Whether the occurrence of postoperative dysphagia can be predicted by oesophageal motility testing performed preoperatively remains a matter of debate. However, some encouraging data suggest that subtle, subclinical dysfunctions of motility, detectable by combined pressureimpedanc e analysis 52,53 and/or multiple rapid swallow testing, 54 could predict susceptibility to postoperative dysphagia. Although these data are preliminary, they suggest the potential for an individual patient's risk for dysphagia to be better quantified than is currently possible.…”

Practical aspects of high resolution esophageal manometry

“…Drinking from the cup is more physiological but not always easier, because if more than three seconds elapse between swallows the test is no longer valid (94). The RS test is especially suitable for patients with hypomotility, as it allows the functional peristaltic reserve that has been linked with the appearance of dysphagia after fundoplication (91,95,96) to be assessed.…”