j gastrointest surg 2012_highres_manometry

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ORIGINAL ARTICLE

High-Resolution Manometry Patterns of Lower

Esophageal Sphincter Complex in Symptomatic

Post-Fundoplication Patients

Masato Hoshino & Ananth Srinivasan & Sumeet K. Mittal

Received: 4 November 2011 /Accepted: 14 December 2011 /Published online: 10 January 2012# 2012 The Society for Surgery of the Alimentary Tract

Abstract

Introduction There has been an increase in the number of patients seeking treatment after an anti-reflux surgical procedure.

The objective of this study is to describe high-resolution manometry (HRM) topography as it relates to the post-

fundoplication anatomy.

Methods Retrospective review of a prospectively maintained database was conducted to identify patients who underwent

esophagogastroduodenoscopy and HRM at Creighton University Medical Center (CUMC) between November 2008 and

October 2010, for symptoms after a previous fundoplication. Patients were categorized as having intact, intrathoracic,

disruptured, twisted, or slipped fundoplication based on endoscopic findings.

Results Sixty-one patients {intact, 17(28%), disrupted, 2(3%), twisted, 3(5%), intra-thoracic, 18(30%), slipped, 21(34%)}

are included in this study. A double high-pressure zone (HPZ) configuration was identified in both intra-thoracic and

slipped fundoplication. This was not noted in appropriately positioned fundoplications. In intra-thoracic fundoplications,

the HPZ below the fundoplication was lower pressure and showed respiratory variations. In slipped fundoplication, the

higher HPZ had lower pressure and no respiratory variations. In appropriately positioned fundoplication, the lower

esophageal sphincter (LES) pressure and extent of relaxation in the single HPZ correlated with intact (normal pressure

and good relaxation), disrupted (low pressure and good relaxation), and twisted (high pressure with incomplete

relaxation) fundoplication. Patients with only a recurrent para-esophageal hernia had characteristics of an appropriately

positioned fundoplication.

Conclusion LES complex HRM findings correlate well with anatomical status of the fundoplication.

Keywords High-resolution manometry (HRM) .

Fundoplication . Lower esophageal sphincter (LES)

Introduction

Anti-reflux surgery (ARS) for refractory gastro-esophageal

reflux disease (GERD) has satisfactory long-term outcome

in greater than 90% of patients.1 – 3 Remaining patients report

either recurrence of symptoms or development of undesirable

side-ef f ects and a subset of these patients require re-operative

ARS.4 – 11 Comprehensive evaluation including upper endos-

copy, contrast study, manometery, selective 24 h pH study,

and gastric emptying study may be done prior to re-operative

intervention.11 Assessment of fundoplication competence and

the association of various anatomic distortions with patient ’s

symptoms are important.12

Advent of high-resolution manometry (HRM) has allowed

for improved diagnostic assessment of esophageal function.

Abstract presented at the American College of Surgeons 97th AnnualClinical Congress, Surgical Forum, San Francisco, CA, October 2011.

M. Hoshino : A. Srinivasan : S. K. Mittal (*)Department of Surgery, Creighton University Medical Center,601, North 30th Street, Suite 3700,Omaha, NE 68131, USAe-mail: [email protected]

S. K. MittalDepartment of Surgical Gastroenterology and Liver Transplant,Sir Ganga Ram Hospital,Delhi, India

J Gastrointest Surg (2012) 16:705 – 714

DOI 10.1007/s11605-011-1803-4



The color-coded display of the pressure topography offers

increased ease of interpretation and detection of hiatus hernia

when compared to conventional manometery.13 – 16 HRM has

replaced conventional manometry as the gold standard for

assessing esophageal function. There are multiple channels

in close proximity along the length of the catheter and traverse

the lower esophageal sphincter (LES), the esophageal body,

and the upper esophageal sphincter (UES) simultaneously.This allows for shorter procedure times as well as compen-

sates for any swallow associated movement of the catheter.

The pressure changes across the length of the esophagus are

displayed as a color contour plot format which makes inter-

pretation easier and more intuitive. A new classification based

on HRM has been proposed and widely accepted.13,14

The fundoplication alters LES and crus configuration.

The intrinsic LES and extrinsic crus compression along with

pressure effects of the fundoplication determine the distal

esophageal high pressure zone (HPZ) pressure topography.

Simultaneous interplay of these factors determines the com-

petence of the sphincter (to prevent reflux) and its compli-

ance (to allow passage of the food bolus). There is paucity

of literature pertaining to HRM pressure topography of the

distal esophageal HPZ after an ARS. The objective of this

study is to evaluate HRM distal esophageal HPZ and LES

parameters in post-fundoplication patients with different

(endoscopic) patterns of failure.

Material and Methods

All patients undergoing esophageal function testing at the

esophageal center at Creighton University Medical Center

are entered in a prospectively maintained database. The labo-

ratory, first established in 1984, has served as a tertiary referral

center for diagnostic evaluation. Since 2008, we have includ-

ed HRM in our armamentarium. After institutional review

board approval, the database was queried to identify patients

who underwent HRM at the esophageal center after a previous

fundoplication. Patients till October 2010 are included in the

study. To clearly associate HRM distal esophageal HPZ pat-

terns in various types of failures only patients who underwent

endoscopy (within 1 week of manometery) by the senior

author (SKM) are included in this study. Patients completed

a standardized symptom questionnaire administered by the

esophageal laboratory nurse prior to testing. This included

symptoms: heartburn, regurgitation, dysphagia, and chest pain

(Appendix A) on a scale of 0 – 3. The patients with grade 2 and

3 were considered to have significant symptom.

Endoscopy

Upper endoscopy was performed in the left lateral decubitus

position under conscious sedation. Detailed assessment of

the fundoplication was done as described by our group

elsewhere.12 A note was made of the location of the

gastro-esophageal junction (GEJ) in relation to the fundo-

plication and the crus, competence, and symmetry of the

fundoplication and the spatial orientation of the fundoplica-

tion with the crus. The endoscopic terms used to describe

the fundoplication changes are: (1) intact fundoplication, (2)

disrupted fundoplication, (3) twisted fundoplication, (4)intra-thoracic fundoplication, and (5) slipped fundoplica-

tion. Twisted fundoplication is not a universal term. The

anterior and posterior fundoplication tucks are asymmetri-

cal, with one deeper and more twisted in appearance than

the other fundoplication tuck. Detailed endoscopic descrip-

tion of these has been given previously by our group.12

High-Resolution Manometry

Combined high-resolution solid state manometry and im-

pedance manometry catheter (Sandhill Scientific Inc., High-

land Ranch, CO, USA) was used. For the purpose of this

study, impedance tracings were not evaluated. The catheter

has 32 solid state pressure sensors placed 1 cm apart and

five dual impedance sensors 5 cm apart. The manometry

study was performed after trans-nasal positioning of the

catheter and in supine position. The distal esophageal HPZ

was identified, and the catheter was positioned such that two

sensors were below the LES to measure the gastric pressure.

Esophageal baseline pressure and pressure in the HPZ in the

distal esophagus were recorded. Esophageal body function

was assessed with ten liquid swallows (5 cc) and ten viscous

swallows (5 cc). During respiratory cycle, normal variation

is noted in luminal pressure, the pressure wave within the

thoracic esophagus is opposite to than within the abdominal

esophagus/stomach. The respiratory inversion point (RIP) is

where the respiratory variation changes from an abdominal

to thoracic pattern, and this marks the proximal limit of the

abdominal segment of the LES. The proximal border of the

LES is the channel at which the pressure falls below the

esophageal baseline. The pressure topography was analyzed

using the Bio View Analysis software (Sandhill Scientific

Inc., Highland Ranch, CO, USA).

Chicago classification13,14 was incorporated into Bio

View analysis soft ware (version M) (Sandhill Scientific

Inc., Highlands Ranch, CO, USA) in October 2010. All

studies were reanalyzed using updated software for this

study. The basal LES pressure was calculated without any

swallows as the pressure within the LES complex. The

abdominal length (AL) and total length (TL) of the LES

was calculated using tracing mode. AL is the distance be-

tween the distal border of the LES and the RIP. TL is the

distance between the distal and proximal borders of the

LES. The adequacy of LES relaxation was assessed by

calculating the integrated relaxation pressure (IRP). IRP is

706 J Gastrointest Surg (2012) 16:705 – 714



the mean of lowest relaxation pressures measured within the

LES for a minimum of 4 s during a swallow. Esophageal

body function was assessed by distal contraction integral

(DCI). DCI is a parameter that integrates the length (centi-

meter), contractile pressure (mmHg), and duration (second)

of contraction.

Representative HRM pressure topography without

previous fundoplication is shown in Fig. 1a , b.

Without Hiatus Hernia Figure 1a shows HRM pressure

topography in a healthy volunteer without a history of

fundoplication. There is a single distal esophageal HPZ with

adequate LES length (AL>1, TL>2 cm) and basal LES

pressure (LESP010 – 35 mmHg) with good relaxation

(IRP<15 mmHg).

With Hiatus Hernia Figure 1b shows a classical double HPZ

seen in with hiatus hernia. The distal HPZ represents the

crus which shows significant respiratory variation while the

proximal HPZ represents with native LES which shows

deglutitive relaxation.

24 h pH Study

This was performed using either a catheter-based system

(Digitrapper 400pH®; Medtronic, Minneapolis, MN) or a

capsule-based system (Bravo®; Medtronic, Minneapolis,

MN). The pH probe was passed trans-nasally and positioned

5 cm above the upper border of the manometrically defined

LES while the capsule was passed trans-orally and posi-

tioned 6 cm above the endoscopic gastro-esophageal junc-

tion. For the capsule based system, the pH<4 fraction time

was the mean of the scores over 2 days. A positive pH study

was one where the total time pH<4 for >4.2% of the study

time.

Statistical Analysis

Medians with interquartile ranges (IQR) are expressed for

continuous variables. Chi-square test was used to compare

categorical variables. Kruskal – Wallis test and Mann –

Whitney’s U test were used to compare continuous variables.

A p value<0.05 was considered significant. SPSS version 17

(SPSS, Inc, Chicago, IL, USA) was used for all statistical

analysis.

Results

During the study period, 331 patients underwent HRM at

the esophageal center. After excluding 250 patients without

history of fundoplication and 20 patients without esophago-

gastroduodenoscopy [(EGD) within 7 days] 61 patients met

inclusion criteria. There were 45 (74%) females and the

median age for the cohort was 58 years (range 25 – 85 years).

Based on endoscopic assessment, there were 17 intact fun-

doplications, 2 disrupted fundoplications, 3 twisted fundo-

plications, 18 intra-thoracic fundoplications (13 patients

IRP Basal LESP

Without hiatushernia(no fundoplication)

With hiatus hernia (no fundoplication)

IRP Basal LESP

Diaphragmatic Hiatus

a

b

Fig. 1 a The HPZ pressuretopography in a healthyvolunteer at 20 mmHg isobariccontour. There is a single distalHPZ comprising of the LES andthe crus. IRP is within normallimits. Basal LES pressure isalso within normal limits. HPZ

high pressure zone, IRP

integrated relaxation pressure, LES lower esophagealsphincter. b The HPZ pattern of a patient with hiatus hernia. Thedistal HPZ represents the regionof the crus with significant

respiratory variations while the proximal HPZ represents thenative LES which showsdeglutitive relaxation. HPZ

high pressure zone, LES lower esophageal sphincter

J Gastrointest Surg (2012) 16:705 – 714 707



with intact, 5 patients with disrupted), and 21 slipped

fundoplications (Table 1).

Table 1 compiles the manometry and 24 h pH study

results with endoscopic findings. Thirty-one patients under-

went 24 h pH study of whom 20 (65%) has a positive score.

Two patients with endoscopically assessed intact infra-

diaphragmatic fundoplication were noted to have a double

HPZ, both these patients also had a positive pH score.When compared with intact, patients with disrupted

intra-thoracic and slipped had lower basal LES pressure

(15.9 vs. 21.8, 16.3 vs. 21.8, both p<0.05), patients with

twisted had higher IRP (37.0 vs. 22.0, p <0.05). There was

no difference in DCI. A double HPZ configuration could

be clearly identified in 12/18 (67%) intra-thoracic fundo-

plications (9/13 intact and 3/5 disrupted) and 16/21 (75%)

slipped fundoplications. In remaining patients, probably

the spatial separation of the native GEJ, the fundoplication

and the crus is not sufficiently large enough to clearly

allow distinct identification of double HPZ. There was no

apparent symptom difference between the patients with

and without double HPZ within each group (intra-thoracic

and slipped). Across the spectrum of anatomic configura-

tions, there was good agreement between manometry find-

ings and endoscopic assessment.

There was no significant difference in reported symptoms

in the sub-categories. Ten patients with intact fundoplication

had a high IRP, of these, 8 patients (80%) reported dysphagia.On the other hand, 3 (43%) patients with normal IRP also

reported dysphagia.

Corresponding distal esophageal HRM pressure topogra-

phy could be identified for each of these anatomical config-

urations (Fig. 2a – f ). Of these, three patients also had pressure

topography consistent with an aperistaltic body (Fig. 2g).

1. Intact fundoplication (Fig. 2a ): In patients with intact

fundoplication, there is a single distal HPZ. The LES

configuration is slightly longer (AL03 and TL05 cm)

and with higher LES pressure (28.9 mmHg) than

Table 1 Individual descriptions of sub-categories, with respect to demographic variables

Intact (17) Disrupted

(2)

Twisted

(3)

Intact intra-thoracic

(13)

Disrupted intra-thoracic

(5)

Slipped (21) p value

Symptoms (n061)

Heartburn 9 (53%) 1 (50%) 1 (33%) 8 (62%) 3 (60%) 11 (52%) 0.968

Regurgitation 9 (53%) 2 (100%) 1 (33%) 7 (54%) 4 (80%) 16 (76%) 0.332

Dysphagia 11 (65%) 1 (50%) 2 (67%) 6 (46%) 1 (20%) 10 (48%) 0.591

Chest pain 7 (41%) 1 (50%) 2 (67%) 4 (31%) 1 (20%) 11 (52%) 0.642

LES and body contraction findings on HRM (n061)

Basal LES pressure (mmHg) 21.8 (17.6 – 35.4)d, e 11.8 (NA) 39.8 (NA) 20.1 (10.4 – 22.9) 15.9 ( 6.7 – 19.5) 16.3 (10.3 – 21.2) 0.028

Low basal LES pressure(<10 mmHg)

0/17 1/2 0/3 3/13 1/5 5/21 0.229

High basal LES pressure

(>35 mmHg)

4/17 b 0/2 3/3 1/13 0/5 3/21 0.005

IRP (mmHg) 22.0 (11.2 – 27.1) b 7.5 (NA) 37.0 (NA) 20.2 (7.5 – 36.4 ) 1 2.7 (4.7 – 14.1) 23.0 (14.0 – 28.7) 0.038

High I RP ( >15 m mHg) 10/17d 0/2 3/3 7/13 0/5 16/21 0.011

Double HPZ (n031) 2/17a, c, d, e ½ 0/3 9/13 3/5 16/21 0.001

DC I ( mmHg- s- cm) 35 64 ( 2,29 9 – 6,633) 517 (NA) 4631 (NA) 2575 (1,574 – 3,833) 2,127 (2,033 – 6,531) 3,141 (2,539 – 6,471) 0.149

24 h pH study findings (n031)

Fr ac tion time pH > 4.0 0.2 ( 0 – 5.5)d, e 6 .0 ( NA) 0 (N A) 6.1 ( 4.1 – 18.5) 21.8 (NA) 14.9 (3.1 – 29.6) 0.017

Positive pH (>4.2%) 3/9 1/1 0/1 3/4 3/3 10/13 0.113

Surgical procedure (n030)

Redo fundoplication (n012) 1/17 0/2 0/3 3/13 2/5 6/21 0.334

RNY (n018) 1/17 1/2 1/3 5/13 1/5 9/21 0.186

Values expressed as median (IQR)

LES lower esophageal sphincter, IRP integrated relaxation pressure, HPZ high pressure zone, DCI distal contractile integral, RNY Roux-en-Yreconstruction, NA not availablea Two patients with positive pH had dual HPZ indicating abnormal post-fundoplication physiology although the EGD showed an infra-diaphragmatic fundoplication b Intact vs. twisted p<0.05c Intact vs. intact intra-thoracic p<0.05d Intact vs. disrupted intra-thoracic p<0.05e Intact vs. slipped p<0.05




healthy volunteers. There is adequate relaxation (IRP<

15 mmHg) and the distal esophageal swallow as normal

contour and wave progression.

2. Disrupted fundoplication (Fig. 2b ): In a patient with

disrupted fundoplication, there is a single distal HPZ.

However, there is decreased basal LES pressure

IRP Basal LESP

Twisted fundoplication

IRP Basal LESP

Intact fundoplication

IRP Basal LESP

Disruptedfundoplication

F ig. 2 a The HRM pressure topography of a patient with intact fundoplication. Compared to a healthy volunteer, the basal LES pres-sure is higher, but there is good LES relaxation during deglutition asthe IRP is within normal limits. LES lower esophageal sphincter, IR P

integrated relaxation pressure. Endoscopic picture reprinted from [12].b Disrupted fundoplication. There is good relaxation with deglutition;however, the basal LES pressure is lower than in an intact fundoplica-tion. LES lower esophageal sphincter. c The HPZ pressure pattern of a patient with a twisted fundoplication is shown in Fig. 2c. One can seethe high basal LES pressure and a lack of deglutitive relaxation asshown by a high IRP. Additionally, one can see high contractions and pressures in distal esophagus with high DCI and is indicative of outflow obstruction. These patients usually present with dysphagia or

chest pain rather than reflux symptoms. LES lower esophageal sphinc-ter, IRP integrated relaxation pressure, DCI distal contractile integral. d

The HPZ pressure topography of an intact intra-thoracic fundoplica-tion. In this patient, the HPZ is split into two: the distal HPZ representsthe crus as the pattern indicates. The fundoplication is represented bythe proximal HPZ. There is adequate pressure in the fundoplicationwith good relaxation as measured by a normal IRP. Such patientsusually present with post-prandial chest/epigastric discomfort due to

distention of the herniated stomach. HPZ high pressure zone, IRP

integrated relaxation pressure. e HRZ patterns in a patient with dis-rupted intra-thoracic fundoplication. The distal HPZ represents thecrus. The proximal HPZ represents the area of the disrupted fundopli-cation. The basal LES pressure is low and there is a normal IRP. Thelow LES pressure indicates a disrupted fundoplication. HPZ high pressure zone, IRP integrated relaxation pressure, L ES lower esopha-geal sphincter. Endoscopic picture reprinted from [12], with permissionfrom Springer. f The HRZ patterns in a patient with slipped fundopli-cation. The proximal HPZ is the native LES and has low basal LES pressure with complete relaxation (normal IRP). The fundoplication isat the level of the crus. The diaphragmatic HPZ overlaps the fundopli-cation. As a result, there is no deglutitive relaxation of the fundoplica-

tion. HPZ high pressure zone, LES lower esophageal sphincter, I R P integrated relaxation pressure. Endoscopic pictures reprinted from [12],with permission from Springer. g Secondary achalasia is shown inFig. 2g. These patients have aperistaltic esophageal body contractions.There is only a single HPZ pressure topography, but the LES pressureand the IRP are high. HPZ high pressure zone, LES lower esophagealsphincter, IRP integrated relaxation pressure




(4.7 mmHg) and a somewhat shorter length of the

LES (AL01 and TL02 cm) compared to intact fun-

doplication and healthy volunteers. There is adequate

relaxation (normal IRP).

3. Twisted fundoplication (Fig. 2c ): Patients with twisted

fundoplication also have a single distal HPZ. There is

generally a high LES pressure along with impaired

deglutitive relaxation (high IRP). Additionally, the distal

esophageal body contractions show a high contractile

vigor indicating outflow obstruction.

4. Intra-thoracic fundoplication (Fig. 2d, e ): There is a

distinct double-hump configuration in the distal esoph-

agus. The distal HPZ represents the crus and shows

exacerbated respiratory variations. The proximal HPZ

is the fundoplication around the native LES. Depending

on the competency of the fundoplication, there is


Basal LESP

Intact intra-thoracic fundoplication


Basal LESP

Disrupted intra-thoracic fundoplication

Basal LESP

Fundoplication

Slipped fundoplication

Secondary achalasia

IRP Basal LESP

Aperistaltic body contraction

Fig. 2 (continued)




adequate (Fig. 2d) or inadequate (Fig. 2e) basal LES

pressure. There is adequate relaxation as observed from

normal IRP.

5. Slipped fundoplication (Fig. 2f ): In patients with

slipped fundoplication, there is also a double hump

configuration. The native LES is the proximal HPZ. In

these patients, the fundoplication is slipped onto the

stomach and is at the level of the crus and is represented by the distal HPZ. In contrast to the intra-thoracic

fundoplication, the distal HPZ does not show the either

exacerbated respiratory variations nor a deglutitive

relaxation. The proximal HPZ shows deglutitive

relaxation.

6. Secondary/missed achalasia (Fig. 2g ): Three patients

had an aperistaltic esophageal body. These could be

either missed achalasia or post-fundoplication achalasia.

All three patients either had an intact or a twisted

fundoplication.

Discussion

HRM has given a clearer understanding of the relationship

between the LES and the crus and their interplay in main-

taining sphincter competence. A double hump distal esoph-

ageal HPZ configuration is consistent with a structurally

defective hiatus.15,16 Tatum et al.17 described HRM manom-

etry findings in post-fundoplication patients and found that a

double hump configuration and low LES pressure correlates

with abnormal distal esophageal acid exposure. In the pres-

ent study, we have demonstrated that different anatomical

configurations of a failed fundoplication have distinct HRM

patterns. This may help better understand mechanisms of

failure.

There has been a dramatic increase in number of

patients undergoing re-operative intervention after previ-

ous ARS.9,10 Detailed anatomical and physiological as-

sessment with in depth understanding of mechanism of

failure is essential prior to redo-ARS. Jobe et al.18 de-

scribed endoscopic assessment of different normal fundo-

plication configurations. Endoscopic configuration of

post-fundoplication anatomy indicates type and cause of

failure.11 On the other hand, Gopal et al.19 concluded

that endoscopic ultrasoundscopy (EUS) gives detailed

anatomic relationship between fundoplication and hiatus.

EUS may enable a precise determination of the anatomic

causes of failure after ARS; however, availability of

equipment and expertise is limited.

HRM allows for in depth assessment of the distal

esophageal HPZ and is able to pick up variations which

were not discernable with conventional manometry. An

appropriately positioned fundoplication lies around the

native LES and is below the crus. This is represented by

a single HPZ. The dual HPZ indicates spatial separation

of this complex and implies failure. HRM allows to fur-

ther distinguish between different types of failures, i.e.,

whether the fundoplication has slipped on to the stomach

and the GEJ has migrated into the chest (slipped fundo-

plication) or that the entire GEJ/fundoplication complex

has migrated into the chest through a lax hiatus (intra-

thoracic fundoplication). Patients deemed to have a dis-rupted fundoplication on endoscopic assessment had

shorter HPZ length and decreased baseline pressure.

Patients with twisted fundoplication have a high LES

pressure and a high IRP implying incomplete relaxation.

Lack of significant symptom correlation with HRM and

24 h pH study results was most likely due to the small

sample size. Two patients with endoscopically assessed

intact infra-diaphragmatic fundoplication were noted to

have a dual HPZ. This leads us to believe that maybe

the fundoplication could be telescoping into the chest

intermittently. Interestingly, both these patients also had

a positive 24 h pH study. HRM could be potentially most

useful in assessing the symptomatic post-fundoplication

patients with an endoscopically intact (seemingly)

fundoplication, probably a more rigid determination of

“intact wrap” using the 10 point criteria laid out by

Jobe et al.18

There are several limitations of this study. Foremost

being that all evaluated subjects are patients with post-

fundoplication complaints and as such there are no con-

trols of asymptomatic post-fundoplication patients. We are

in the process of performing HRM and endoscopic assess-

ment in a cohort of asymptomatic post-fundoplication

patients so that normal length, pressure, and residual pres-

sure values can be calculated. This study had a small

sample size, therefore statistical power is low and type 2

error cannot be ruled out. Another limitation is the lack of

symptom association. However, there is good correlation

with objective reflux testing.

The primary objective of this study was to identify var-

ious HRM findings associated with anatomical failures. This

will allow further work in understanding mechanisms of

failure and assessing symptoms association, especially in

the symptomatic post-fundoplication patients with a seem-

ingly (endoscopic) intact fundoplication.

Conclusion

Distal esophageal HPZ – HRM findings correlate well with

anatomical status of the fundoplication. The introduction

of HRM findings for failed fundoplication may be help-

ful for assessment of symptomatic patient prior to re-

intervention. Further study is needed to understand symptom

correlation.




Author Disclosure Drs. Masato Hoshino, Ananth Srinivasan, andSumeet K. Mittal have no conflicts of interest or financial ties todisclose.

Appendix

Post-Procedure Questionnaire

Name ____________________________ Date of follow-up __________________________

DOB ____________________________ Sex __________ Data sheet # ___________

Phone number ____________________ Duration since surgery _____________________

Procedure ________________________ Date of procedure _________________________

HEARTBURN

________ times a day/week/month

0 – None

1 – Minimal – episodic, no treatment is required

2 – Moderate – controlled with medication

3 – Severe - interferes with daily activity or not controlled with medication

DYSPHAGIA

0 – None

1 – Once a week or less

2 – More than once a week, requiring dietary adjustment

3 – Severe – preventing ingestion of solid food

REGURGITATION


0 – None

1 – Mild – after straining of large meal

2 – Moderate – positional

3 – Severe – constant regurgitation with or without aspiration




CHEST PAIN


0 – None

1 – Minimal – episodic

2 – Moderate – reason for visit

3 – Severe - interferes with daily activity

NAUSEA / VOMITING


0 – None

1 – Minimal – episodic

2 – Moderate – reason for visit

3 – Severe - interferes with daily activity

ABDOMINAL BLOATING Yes No

OTHER SYMPTOMS _______________________________________________

MEDICATION

None

Antacids Name _____________ Dose ________ Started by/on __________

H2 blockers Name _____________ Dose ________ Started by/on __________

PPI Name _____________ Dose ________ Started by/on __________

Prokinetics Name _____________ Dose ________ Started by/on __________

WEIGHT _____________

GRADING RATE

How satisfied are you with your surgical outcome? (scale 1-10, 1-worse/10-best) ________

Would you recommend this procedure to a friend? Yes No




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