Esophageal manometry findings after fundoplication

Fundoplication changes the pressure barrier at the gastro-oesophageal junction (GOJ), so high-resolution manometry (HRM) after surgery rarely looks identical to a pre-operative study. A tighter lower oesophageal sphincter, altered relaxation and preserved swallowing contractions may all be expected. The clinical meaning depends on symptoms, surgical technique and the time since the operation.

For Australian patients, testing is usually arranged through a gastroenterologist or upper gastrointestinal surgeon, often after a GP referral. A person treated in a public hospital in Sydney, Melbourne or Brisbane may follow a different pathway from someone using a private motility laboratory, while rural patients may need travel or telehealth support for specialist review.

The ISDE 2021 congress focused on international education and research in oesophageal disease. Its scientific context is useful here: manometry findings should be interpreted alongside endoscopy, contrast imaging and the patient’s recovery, rather than treated as an isolated diagnosis.

Why manometry is used after surgery

Persistent dysphagia, chest discomfort, regurgitation or difficulty swallowing liquids can prompt HRM after fundoplication. The test measures the strength and coordination of oesophageal contractions and assesses how the GOJ relaxes during a swallow.

Manometry may help distinguish an overly tight or misplaced wrap from recurrent reflux, ineffective oesophageal motility or an unrelated swallowing disorder. It is generally most informative once early postoperative swelling has settled, although urgent assessment may be needed when swallowing is severely restricted or dehydration develops.

Expected pressure changes

A successful fundoplication commonly increases the resting pressure of the lower oesophageal sphincter and the contractile barrier at the GOJ. The integrated relaxation pressure (IRP) can also rise because the wrap resists opening during swallowing.

These values must be compared with the laboratory’s reference range and the surgical anatomy. A mildly elevated IRP does not automatically prove obstruction. The patient may have normal bolus passage, intact peristalsis and improving symptoms despite an abnormal-looking number.

Peristalsis and contractile strength

Most patients retain coordinated oesophageal contractions after a standard fundoplication. HRM may show normal peristalsis, stronger distal contractions or occasional weak swallows. The distal contractile integral (DCI) can assist interpretation, but it should not be read without considering bolus transit and symptom timing.

Absent contractility, frequent failed swallows or severe ineffective motility can make swallowing more difficult when the GOJ has been tightened. These patterns may have been present before surgery, which is why pre-operative manometry is valuable whenever available.

Recognising possible outflow obstruction

A raised IRP with intact peristalsis may suggest oesophagogastric junction outflow obstruction (EGJOO), but a fundoplication itself can create this manometric pattern. Chicago Classification version 4.0 emphasises supportive evidence, such as abnormal upright measurements, impaired bolus clearance or corroborating symptoms.

Clinicians may use a timed barium swallow, barium tablet study or endoscopy to see whether the wrap is too tight, slipped or herniated. A normal endoscopy does not exclude a functional problem, and an abnormal manometry result does not establish that the wrap requires revision.

Matching results with symptoms

Postoperative dysphagia during the first weeks can improve as inflammation decreases and swallowing adapts. Ongoing solid-food obstruction, liquid dysphagia or progressive symptoms carry more weight than a borderline pressure elevation.

Reflux symptoms also need careful separation from functional complaints. Regurgitation, belching and chest pressure can occur without recurrent acid exposure. Ambulatory pH-impedance monitoring may be appropriate when reflux recurrence is suspected, while endoscopy can assess oesophagitis, narrowing and the position of the wrap.

Practical interpretation in Australia

Access to oesophageal physiology testing varies between metropolitan and regional services. A patient from regional Queensland or Western Australia may have HRM performed during a visit to a tertiary centre, with results discussed later by video. Public waiting times and private fees can differ, so the referring specialist usually explains the local pathway.

Reporting points that support decisions

A useful report states the operation when known, including whether the wrap was Nissen, Toupet or another configuration. It should describe supine and upright positions, the IRP, resting pressure, peristaltic pattern, DCI, intrabolus pressure and any provocative manoeuvres used.

Practical points for a clear specialist review include:

• Compare the study with pre-operative manometry whenever possible.
• Record whether dysphagia affects solids, liquids or both.
• Check for supportive evidence before labelling EGJOO.
• Correlate the result with endoscopy, contrast imaging and reflux monitoring.
• Consider the time since surgery and the patient’s nutritional status.

A result should guide the next investigation, not dictate treatment by itself. In Australia, the GP, gastroenterologist and upper gastrointestinal surgeon may coordinate care across public and private services, particularly when symptoms persist after an initial reassuring test.

For a patient with ongoing postoperative dysphagia, the concrete next step is to arrange a specialist review with the manometry report, operative details and any pre-surgery investigations available.