Abnormal preoperative and postoperative esophageal peristalsis in gastroesophageal reflux.

Extended 24-hour pH monitoring and esophageal manometry before and 6 months after Nissen fundoplication in a group of 14 children with symptomatic gastroesophageal reflux (GER), of whom 12 had esophagitis, have shown that all patients were clinically cured and their initially abnormal pH-monitoring parameters significantly decreased to normal values after operation. Whereas lower esophageal sphincter pressure (LESP) was not modified by surgery, lower esophageal sphincter length (LESL) was significantly increased. The percentage of tertiary, nonpropulsive esophageal waves, that was very high in basal conditions (74.9 +/- 34.5%) and following instillation of acid into the esophagus (79.8 +/- 20.2%) remained high (58 +/- 23.2% and 72.1 +/- 18.2% respectively) several months postoperatively. The persistence of abnormal peristalsis after surgical cure of GER suggests that severe symptoms in this group of patients resulted from the simultaneous failure of both components of the antireflux mechanism (LES and esophageal peristaltic "pump"), which led to increased acid exposure. The good results of surgical establishment of an effective valve-like barrier alone illustrate the possibility of compensation by only one of the components when the other fails. According to this interpretation, whereas patients with good peristalsis would tolerate GER fairly well, those with GER and bad peristalsis would have increased acid exposure and, consequently, esophageal damage.