Ambulatory Esophageal pH Monitoring in Patients with Prior Anti Reflux Procedures

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One of the great fallacies in managing patients with GERD is that pharmacological,endoscopic, or surgical anti-reflux therapy normalizes intraesophageal acid exposure in most patients. The reality is that many GERD patients, even those with complete resolution of heartburn and healing of esophagitis, often have improved but persistent pathological intraesophageal acid exposure, despite apparent adequate pharmacological, endoscopic, or surgical therapy. Thus, pathological intraesophageal acid exposure after anti-reflux surgery in of itself is not necessarily indicative of a failed surgical procedure. A postoperative esophageal pH assessment is difficult to reconcile with postoperative symptoms if the preoperative pH values are not known and unless a symptom correlation is performed between reflux events and symptoms with the follow-up study. Unfortunately, this later symptom assessment during interpretation of pH monitoring is not routinely performed by all that read these tests, but in the case of suspected postoperative GERD, a symptom correlation should be part of the routine assessment of these tracings. Clearly, unimproved or worsening intraesophageal acid exposure from preoperative to postoperative studies is likely to suggest an incompetent repair as does a good correlation between symptoms and reflux events.21 In cases in which there has been a decrease or normalization of esophageal acid exposure between studies and no or little correlation with symptoms, then it is unlikely that reflux related to a defective surgical repair is responsible for the patient's postoperative symptoms. Whether a dual probe assessing proximal as well as the more usual distal esophageal acid exposure or a 48-hour study with the Bravo system (Medtronics, Minneapolis, MN) increases the sensitivity of this physiological test in the postoperative state is unknown. Our personal bias is that patients are more tolerant of the tubeless Bravo probe and more likely to maintain normal diet and activity while being studied and therefore more likely to demonstrate pathological reflux

MANAGING FAILED ANTI-REFLUX THERAPY

if present. However, not all centers performing anti-reflux surgery evaluations have access to a Bravo system nor has it been shown to improve diagnostic outcome in this specific clinical situation.

Other Tests of Gastrointestinal Physiology and Function

Esophageal manometry has been used in the past to assess the length of the LES, its pressure, and intraabdominal location as a surrogate of valve competency after surgical treatment of GERD. There are no data demonstrating that this is a reliable means of assessing postsurgical valve competence, but nonetheless the procedure has been widely adopted and implemented into clinical practice.21 Our experience suggests that the normal range in length and pressure of the LES after otherwise effective anti-reflux surgery is so great that unless the pressure is minimal (<8mmHg) or the length is extremely short, competency of the valve in the postoperative state is nearly impossible to determine by this test alone. However, manometry can be complementary to other tests of valve function (e.g., endoscopy, pH monitoring) or diagnostic when other unusual diseases that can mimic GERD in the postoperative state are present (e.g., achalasia).

The barium swallow has also been used in the past to detect recurrent hiatus hernia or marked displacement of wrap location after anti-reflux surgery.21 However, this test is only sensitive to gross disruption of the surgical repair, and likely adds little to the preferred method for assessing valve anatomy after anti-reflux surgery, a careful and descriptive endoscopic examination (Table 10.1).

Endoscopic and Pharmacological Therapy after Failed Anti-Reflux Surgery

Once it has been objectively determined through the above diagnostic testing strategy that the symptoms the patient has are related to continued or recurrent reflux, the next decision one needs to make is how best to manage the patient's GERD. Options include repeat anti-reflux surgery in centers with skill and experience in this type of surgery, endoscopic anti-reflux procedures, or pharmacological anti-reflux therapy. The choice will depend in part on the patient's preference as well as their unique physiology and anatomy as well as the availability of surgical or endoscopic skill in performing these types of procedures. There are no comparative trials in the medical literature evaluating these different management strategies versus each other. Furthermore, although there are numerous case series demonstrating success in treating failed anti-reflux surgery with reoperation,34-56 there is no literature regarding efficacy of anti-reflux endoscopic procedures (despite personal and anecdotal reports of success) and surprisingly little written regarding the utility of standard antireflux drug therapy (although most of us have a firm clinical impression that these drugs perform similarly in the postoperative patient to the efficacy demonstrated in unoperated individuals with GERD).

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