Evaluation

Careful preoperative patient evaluation is the key factor for good surgical results and must include an adequate clinical history, endoscopy, manometry, 24-hour pH monitoring and occasionally video contrast radiography. These are objective and reproducible tests to detect and verify GERD.
After careful clinical evaluation of the GERD patient, endoscopy with biopsies to detect intestinal columnar lining of the esophagus is required. Strictures must be biopsied for exclusion of malignancy. Tight strictures should be dilated before surgery. Furthermore, endoscopy has to exclude other pathologies such as gastritis, gastric ulcer or duodenal obstruction.
The next step in the preoperative evaluation is manometry, to provide information on sphincter function, location and length and esophageal body motility. This information is important to make the correct surgical decision. Furthermore, manometry is useful to place the probe for 24-hour pH monitoring in the correct position. The choice for a laparoscopic Nissen or Toupet fundoplication is based on the assessment of esophageal contractility. Patients with weak esophageal contractions and/or abnormal wave progression should be treated with a partial fundoplication in order to avoid the increased outflow resistance associated with a complete fundoplication. Pressures less than 30 mmHg in response to a wet swallow and > 40% simultaneous or failed contractions are indicative of failed esophagus body contractions.