The document outlines essential preoperative tests and considerations for antireflux surgery, emphasizing the importance of proper diagnostics to ensure better outcomes. It discusses various testing methods such as pH monitoring, impedance testing, manometry, and endoscopy, and highlights cautionary measures before these tests, particularly regarding medication use. The summary also includes specific tests for conditions like Barrett's esophagus and large paraesophageal hernias.

1. ANURAG HOSPITAL, COIMBATORE. WWW.ANURAG-HOSPITAL.COM
TIPS ON TESTS BEFORE ANTIREFLUX SURGERY
Dr PRAVIN HECTOR JOHN
MS, FIAGES, FALS, FIBC
&
Dr JOHN AC THANAKUMAR
MBBS, MS, MNAMS, FRCS (Ed), FRCS (G), Dip MIS (Strasbourg), FICS, FALS.

2. GENERAL COMMENTS
• POOR DIAGNOSIS POOR OUTCOME
• SUCCESS OF REOPERATIONS IS LESS
• SPASTIC DISTURBANCES CAN PRODUCE HEART BURNS

3. OTHER CAUSES OF DEFECTIVE LES AND
ESOPHAGITIS
RED FLAGS
• APART FROM GERD, XEROSTOMIA, HYPO-MOTILITY OF ESOPAHGUS
• DELAYED GASTRIC EMPTYING
• DUODENO GASTRIC REFLUX

4. SO BEFORE SURGERY, CONSIDER
1) THOROUGH HISTORY & COUNSELLING

5. 2) pH MONITORING
• 24 Hour pH for extent of eosphageal exposure to acid
• 24 hour tranasnasal probe or a small capsule (Bravo) attached to mucosa
which transmits pH via radio-teletry
• Both valid & reproducible
• Demonstrates if reflux is postprandial, duration, time of day, with ref to symptoms
• Avoid surgery with normal 24 Hr pH reading - results are poor
SO BEFORE SURGERY, CONSIDER

6. Cautions before pH monitoring
• PPI off for a week
• Histamine H2Blockers off for 2 days
• Beware of cheats who don’t comply
when the pH result is normal
SO BEFORE SURGERY, CONSIDER
Withholding PPI
• Good test when symptoms recur
• If no response, use caution

7. pH TEST NOT ALWAYS NECESSARY
• Obvious defective LES (manometry)
• Obvious esophagitis (endoscopy)
• In very large paraesophageal hernias

8. 3) IMPEDANCE TESTING - (a corollary to 24 pH monitoring)
• Current is conducted by ions on mucosa in empty esophagus
• Liquids with more ions increase conductivity and decrease resistance
• By measuring impedence at various sites in catheter, direction can be made
out as antegrade (bolus) and retrograde reflux(acid)
• Combine pH monitoring with impedance testing - all reflux can be measured
• Impedance testing is useful for cough, with normal pH studies
SO BEFORE SURGERY, CONSIDER

9. 4)MANOMETRY - measures up/lower esophageal sphincters, functions
High resolution manometry with pressure
transducers are useful
1. Oesophago-gastric outflow junctions
2. Major peristaltic disorders (eg nutcracker)
3. Minor peristaltic disorders
SO BEFORE SURGERY, CONSIDER
MANOMETRY WITH IMPEDENCE
1.Guides surgeon to functional surgery
2.Warns of contra-indications for surgery
3.If test impossible, do partial fundo

10. 5)IMPEDENCE MANOMETRY - for different bolus in different positions
• New
• Done with different bolus consistencies in different body positions
• Studies esophageal function before and after surgery
SO BEFORE SURGERY, CONSIDER

11. 6)BARIUM ESOPHAGOGRAM - Functional info of oesophagus
• In pts unable to tolerate manometric studies
• Identifies nature & position of hiatal hernia
• Newer effervescent crystals show
1. Mucosa ( ulcers, infections, tumors)
2. Propulsion of oesophagus
3. Anatomical facts like strictures
4. Free reflux +/-
SO BEFORE SURGERY, CONSIDER
Communicate with radiologist

12. 7) ENDOSCOPY - Critical & biopsy
• HPE- Barrett, ca, eosinophilic esophagitis
• Length of Barrett’s esophagus
• Size of Hiatal hernia
• Presence of esophagitis
• Stricture
SO BEFORE SURGERY, CONSIDER
LOS ANGELES CLASS OF ESOPHAGITIS
A. Grade: mucosal break < 5 mm
B. Grade: mucosal break > 5 mm
C. Grade: mucosal break < 75% Oce
D. Grade: mucosal break > 75% Oce

13. 8) GASTRIC EMPTYING STUDIES
• Radiolabelled low-fat eggwhites with imaging upto 4 hours after meals
• Delayed gastric emptying time mars Nissen fundoplication results
SO BEFORE SURGERY, CONSIDER
RED FLAGS indicate GASTRIC EMPTYING STUDIES
1. Nausea & vomiting
2. Postprandial fulness / bloating

14. In summary -1
TESTS for BARRET’S ESOPHAGUS
1. Endoscopy , biopsy
2. Manometry for hypo motility
TESTS for LARGE PARAESOPHAGEAL HERNIAS
1. Ba / CT studies
2. Endoscopy
PS: Manometry / pH studies not required

15. TESTS for MYOTOMY /DIVERTICULAE
1. Barium / CT
2. Endoscopy
3. Manometry - to assess types
In summary -2
TEST for RE-SURGERY AFTER FUNDO
FAILED FUNO
1. HISTORY
2. Endoscopy
3. CT scans
4. Manometry
5. Gastric emptying studies

16. Thank you
www.anurag-hospital.com