Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing

Figure 1 Twenty-four hours pH studies. A: Normal 24 h pH study showing acid in the stomach without acid reflux events in the esophagus; B: Abnormal 24 h pH monitoring test with multiple acid reflux events in the esophagus (star indicating reflux events).

Figure 2  Abnormal wireless capsule pH study (arrows indicating prolonged reflux events).

Figure 3 Examples of pH-impedance measurements. A: Reflux event recorded during 48 h pH-impedance study; B: Weak acid reflux event in the esophagus without acid exposure in the stomach detected on pH-impedance study (arrows indicating impedance events, star indicating pH drop and acid event).

Figure 4 Utility of pH and multichannel intraluminal impendence pH testing for pre-operative assessment. GERD: Gastroesophageal reflux disease; NERD: Non-erosive reflux disease; PPI: Proton pump inhibitor; AET: Acid exposure time; MII-pH: Multichannel intraluminal impendence pH monitoring.

Figure 5 Utility of high-resolution manometry for pre-operative assessment. LES: Lower esophageal sphincter.

Figure 6 Normal peristalsis and lower esophageal sphincter relaxation on high-resolution manometry. A: Example of normal swallow on high-resolution manometry; B: Normal swallow with complete esophageal clearance by impedance.

Figure 7 Examples of achalasia diagnosed on high-resolution manometry. A: Type I achalasia with failure of lower esophageal sphincter relaxation and absence of peristalsis; B: Type II achalasia with panesophageal pressurization; C: Type III achalasia with abnormal peristalsis (spastic/premature contractions).

Figure 8  Scleroderma esophagus with absent peristalsis and hypotensive lower esophageal sphincter.

Figure 9  Outflow obstruction with elevated residual pressure and distal pressurization from chronic opioid use.

Figure 10  Example of hypercontractile esophagus with distal contractile integral > 8000 mmHg.

Figure 11  Findings on high-resolution manometry with multiple rapid swallow. A: Normal multiple rapid swallow (MRS) with good contraction distal contractile integral; B: Weak esophageal contractions with MRS; C: Failed esophageal contractions with MRS.

Figure 12  Examples of straight leg raise testing during high-resolution manometry. A: Normal straight leg raise test with single pressurization zone; B: Two pressurization zones after straight leg raise indicating presence of small hiatal hernia; C: Example of two pressurization zones after straight leg raise in patient with large hiatal hernia (Arrows indicate pressurization zones).