胃食管吻合术联合Nissen胃底折叠术对食管中段癌患者术后胃食管反流的影响

目的探讨胃食管吻合术联合Nissen胃底折叠术对食管中段癌术后患者胃食管反流的影响。 方法选取2015年9月至2017年3月,新疆维吾尔自治区人民医院住院并行食管癌切除术31例食管中段癌患者的临床资料。根据手术方式分为2组,即接受胃食管吻合术联合Nissen胃底折叠术15例（观察组）,接受胃食管吻合术16例（对照组）,术后2周待患者恢复正常的胃肠道功能后采用pH动态监测仪对其进行24 h pH监测,术后1、3、6、12个月依据胃食管反流病调查问卷（GerdQ）对患者的胃食管反流相关症状进行评分,比较2组患者术后胃食管反流发生情况。 结果2组患者均未出现死亡病例,且术后均未发生有吻合口瘘及胸胃排空障碍等并发症;观察组患者术后2周24 h酸反流次数显著少于对照组、最长酸反流时间和pH值<4的总时间短于对照组,DeMeester评分显著低于对照组,组间比较均有统计学意义（P<0.05）;观察组术后3、6、12个月胃食管反流病调查问卷（GerdQ）评分显著低于对照组,组间比较均有统计学意义（P<0.05）。 结论胃食管吻合术联合Nissen胃底折叠术对食管癌切术后的胃食管反流病情起到更为理想的控制效果,为食管中段癌患者术中吻合术式的选择提供一定参考价值。     

Esophageal motility in reflux disease before and after fundoplication: a prospective, randomized, clinical, and manometric study.

BACKGROUND AND AIMS: The purpose of this study was to determine whether esophageal dysmotility affects symptoms of gastroesophageal reflux disease or clinical outcome after laparoscopic fundoplication and whether esophagus motor function changes postoperatively. METHODS: Two hundred patients with a history of long-standing gastroesophageal reflux disease were investigated by clinical assessment, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring between May 1999 and May 2000. Patients were stratified according to presence or absence of esophageal dysmotility (each n = 100) and randomized to either 360 degrees (Nissen) or 270 degrees (Toupet) fundoplication. At a 4-month postoperative follow-up, preoperative tests were repeated. RESULTS: Preoperative esophageal dysmotility was associated with more severe reflux symptoms, more frequent resistance to medical treatment (64% vs. 49%; P < 0.05), and greater decrease in lower esophageal sphincter pressure (9.5 +/- 5.3 vs. 12.4 +/- 6.7 mm Hg; P < 0.0005) compared with normal motility. Postoperatively, clinical outcome and reflux recurrence (21% vs. 14%) were similar. Esophageal motility remained unchanged in 85% of patients and changed from pathologic to normal in 20 (10 Nissen/10 Toupet) and vice versa in 9 (8 Nissen/1 Toupet) patients. CONCLUSIONS: Esophageal dysmotility (1) reflects more severe disease; (2) does not affect postoperative clinical outcome; (3) is not corrected by fundoplication, independent of the surgical procedure performed; (4) may occur as a result of fundoplication; and (5) requires no tailoring of surgical management.     

The Contribution of Elevated Gastric Pressure to Prevention of Gastroesophageal Reflux in Several Different Antireflux Procedures

Although there are many studies evaluating the effect of elevated gastric pressure in total wrap and partial anterior and posterior wrap fundoplications, there are no ex vivo manometric studies evaluating the contribution of elevated gastric pressure to prevention of gastroesophageal reflux (GER) in Collis and uncut Collis procedures without fundoplication. An experimental study has been designed to determine the contribution of elevated intragastric pressure in the absence of in vivo anatomic and functional factors to the prevention of GER in Collis and uncut Collis without fundoplication procedures. The study was conducted on adult male New Zealand rabbits' esophagus and stomachs. The stomachs were divided into four groups: total wrap fundoplication group, partial wrap anterior fundoplication group, Collis without fundoplication group, and uncut Collis without fundoplication group. The minimum intragastric pressure (MIP) causing GER of each stomach before and after the procedure were measured with a two-way catheter introduced through the pylorus. The MIP values causing GER of the total wrap and partial anterior wrap fundoplication groups were found to be significantly higher compared with the basal intragastric pressures (P < 0.01). The MIP values causing GER of the Collis and uncut Collis without fundoplication groups were not significantly different compared with basal intragastric pressures (P > 0.05). The elevated gastric pressure is found to be insufficient to prevent GER in Collis and uncut Collis without fundoplication procedures. The efficacy of these procedures in preventing GER seems to be related to the anatomic and functional factors affecting in vivo circumstances.     

Manometric characteristics of the gastroesophageal junction after anterior versus posterior partial fundoplication

How best to surgically treat GERD is an unresolved issue. To increase our insights into the fundoplication procedures, functional consequences for the gastroesophageal junction of an anterior or a posterior partial fundoplication were studied by manometry. Patients were randomly selected from a larger study in a randomised comparison between posterior and anterior partial fundoplications. The manometric studies were done 12 months after respective procedures in 24 patients. The motor characteristics of the esophagus and lower esophageal sphincter (LES) function were determined by use of sleeve catheter manometry. The manometric characteristics of the esophageal body were similar in the study groups except for the ramp pressure. This was significantly higher in patients with posterior partial fundoplications. The posterior group had significantly longer total length (P < 0.02) as well as longer intra-abdominal portions (P = 0.07) of the LES while the basal tone, albeit numerically higher, did not reach statistical significance. Water-swallow induced LES relaxations reached lower nadir values in the anterior group (1.7 vs 2.7 mmHg). Gas distension triggered few transient LES relaxations in both study groups while common cavities were more frequently observed in those having an anterior partial wrap (P < 0.01). A posterior partial fundoplication is followed by manometric characteristics suggesting a well functioning antireflux barrier with some obstruction to bolus passage as well as restricted venting of air from the stomach. The manometric mechanisms behind the inferior reflux control achieved by a Watson type of anterior partial wrap has now been further elucidated.     

Illness behavior and laparoscopic antireflux surgery: tailoring the wrap to suit the patient

Psychological factors are believed to play a role in gastroesophageal reflux disease. It has previously been shown that preoperative illness behavior influences the outcome after laparoscopic Nissen fundoplication. Between August 2001 and June 2004 we considered a partly subjective assessment of illness behavior when selecting patients with gastroesophageal reflux disease for laparoscopic anterior partial (n = 77) or total fundoplication (n = 90). A prospective questionnaire study of illness behavior was also undertaken and the results were correlated with clinical follow up after 12 months. There was a statistically significant difference in age (P < 0.001), primary esophageal peristalsis on manometry (P = 0.037) and two illness behavior category scores related to hypochondriasis (P = 0.041 and P = 0.025) between laparoscopic anterior partial fundoplication and Nissen total fundoplication groups. Despite these differences, there was no significant correlation between preoperative illness behavior score and patient satisfaction in either group. There was a statistically significant negative correlation between the ability to express personal feelings and postoperative heartburn score in those who had a laparoscopic anterior partial fundoplication (P = 0.048). The clinical outcome in both groups was good to excellent in terms of postoperative heartburn and satisfaction scores. A tailored approach in the choice of wrap, taking into account psychological factors preoperatively, is an appropriate strategy for laparoscopic fundoplication.     

腹腔镜Nissen和Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的术后效果评价

目的探讨腹腔镜Nissen和Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的疗效和术后并发症。 方法回顾性分析2014年7月至2016年7月,在中国医科大学附属盛京医院行腹腔镜下食管裂孔疝修补联合胃底折叠术的57例食管裂孔疝合并胃食管反流病患者的临床资料,其中24例行Nissen胃底折叠术式(Nissen组),33例行Toupet胃底折叠术式(Toupet组)。观察并比较2组患者的术后抗反流效果及发生术后并发症情况。 结果57例均顺利完成腹腔镜下手术,无中转开腹,手术时间68～115 min,平均手术时间(75.8±6.4)min;术中出血量15～30 ml,平均出血量(22±5)ml;2组患者均使用补片行食管裂孔疝修补术;术后24 h进流食,术后平均住院日(10.5±3)d。2组患者手术时间,出血量,住院日无明显差别。57例患者均得到随访,随访时间为6个月至2.5年,平均随访时间为18个月。术后均未出现反酸,烧心等胃食管反流病典型症状,无复发病例。Nissen组术后有2例(8.2%)患者出现吞咽困难,Toupet组术后有8例(24.2%)出现吞咽困难,Toupet组术后并发症发生率明显高于Nissen组。术前伴有胃食管反流病的患者行胃镜检查均有不同程度的食管炎症,所有患者术后均复查胃镜、食管测压及食管24 h pH值监测。复查结果显示,2组患者术后较术前食管下括约肌压力均有明显改善,食管下括约肌长度也均明显延长。 结论腹腔镜下Nissen术式在术后出现吞咽困难发生率上少于Toupet术式,但2种术式抗反流效果无明显差异。     

Laparoscopic Nissen fundoplication using laparosonic coagulating shears: report of a case

A 64-year-old man was admitted to Gunma University Hospital because of gastroesophageal reflux disease and hiatus hernia. Endoscopic examination showed a linear ulcer and mucosal redness in the lower esophagus. Gastrointestinal contrast study revealed a large esophageal hiatal sliding hernia. Laparoscopic Nissen fundoplication was then performed. Short gastric vessels were divided and lesser omentum was ablated with laparosonic coagulating shears, and the fundus of the stomach was used to construct the wrap around the esophagus. Three hundred and sixty degree fundoplication was undertaken using four sutures to secure the wrap. The patient is well and is currently free from reflux symptoms. Laparoscopic Nissen fundoplication is effective in the control of gastroesophageal reflux in the patient with hiatus hernia. This case report demonstrates that the use of laparosonic coagulating shears is effective for the division of the short gastric vessels.     

Esophageal motor abnormalities in gastroesophageal reflux and the effects of fundoplication

Recordings of esophageal manometry obtained from 18 healthy control subjects and 32 patients with gastroesophageal reflux disease both before and after fundoplication were assessed. Preoperatively, the patients had a mean lower esophageal sphincter pressure at rest that was significantly lower (p less than 0.001) than that observed in the control group. The amplitude of peristaltic contractions, elicited by wet swallows, varied along the length of the esophagus. In patients with gastroesophageal reflux disease, the mean amplitudes recorded from the upper, middle, and lower esophagus were significantly lower (p less than 0.001) than those recorded from control subjects. No significant differences were observed between those patients with (53%) and without preoperative endoscopic evidence of esophagitis. After antireflux surgery (modified Nissen fundoplication), the mean amplitude of peristaltic contractions increased significantly (p less than 0.001) at all levels of the esophagus and were not significantly different from control values. This study describes motor abnormalities in the body of the esophagus associated with gastroesophageal reflux disease. These may arise secondary to gastroesophageal reflux inasmuch as they disappear after fundoplication.     

Antireflux mechanism of Nissen fundoplication. A manometric study.

To analyze the mechanisms by which Nissen fundoplication controls gastroesophageal reflux, the pre- and post-operative manometric findings in 34 patients were compared. The postoperative assessment showed an increase in both the infradiaphragmatic length and basal pressure of the lower esophageal sphincter and a notable improvement in esophageal motility (increase in the amplitude of the waves and decrease in the mean percentage of deglutitions without response and tertiary waves) in those who preoperatively presented with defective esophageal peristalsis.     

Manometric study and prolonged pH monitoring of esophagus in patients with hiatus hernia before and after operation

The pathophysiology of the lower esophagus in 18 patients with hiatus hernia and 15 normal controls was investigated by esophageal manometry and prolonged pH monitoring. Thirteen patients with symptoms of severe gastroesophageal reflux had lower than normal pressures at the gastroesophageal junction. In 5 patients without symptoms, the pressure was normal. Nine of the 13 patients were inadequately controlled by conservative measures and underwent Nissen or Dor-Nissen fundoplication. All were free of esophageal symptoms postoperatively. Fundoplication resulted in a significant increase in the lower esophageal pressure. Prolonged esophageal pH monitoring showed significant improvement in all indices. Hiatus hernia and gastroesophageal reflux are related etiologically. However, further observations are needed to explain the association between reflux esophagitis and hiatus hernia. Nissen and Dor-Nissen fundoplications restored competence to the gastroesophageal junction as judged by esophageal manometry and prolonged pH monitoring.     

Nissen fundoplication in infants and children: a long-term clinical study

BACKGROUND/AIMS: Infants and children who underwent open Nissen fundoplication for gastroesophageal reflux disease were retrospectively evaluated to assess the success and complications of this operation. METHODOLOGY: Twenty-six neurologically normal children (16 boys and 10 girls between 6 months and 11 years old) underwent Nissen fundoplication for intractable or complicated gastroesophageal reflux between October 1982 and February 2002. Before surgery and at follow-up visits, all children were subjected to thorough history, barium meal study and gastroscopy with multiple esophageal biopsies. The median follow-up period was 28 months (range: 11 months-19 years). RESULTS: Persistent vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%), chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth were found in 4 patients (15.4%), hematemesis and/or melena occurred in 2 patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients (15.4%). There was no mortality. The mean hospital stay was 4.1 days. Twenty-two patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases (15.4%). One of these cases had no evidence of recurrent pathological reflux, 2 cases with preoperative stricture developed wrap disruption, recurrent reflux and re-stricture. Both refused a second operation. The fourth case developed melena and reflux esophagitis due to wrap herniation through the hiatus and was successfully managed by a second operation. CONCLUSIONS: Nissen fundoplication is an effective operation to correct gastroesophageal reflux in infants and children when the drug therapy fails. The operation should be done before occurrence of complications to decrease the recurrence of reflux.     

Preoperative esophageal body motility does not influence the outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease.

We evaluated a policy of performing laparoscopic antireflux surgery without tailoring the procedure to the results of preoperative esophageal motility tests. A total of 117 patients (82 with normal esophageal motility; 35 with ineffective motility, IEM) underwent laparoscopic Nissen fundoplication for symptomatic gastroesophageal reflux. There were no significant differences in preoperative symptom length, dysphagia, DeMeester symptom scores, acid exposure times or lower esophageal sphincter pressures between the two groups. Both groups showed postoperative improvements in DeMeester symptom scores, dysphagia and acid exposure, with no differences between groups. At 1 year after surgery, 95% of the normal motility group and 91% of the IEM group had a good/excellent outcome from surgery. None of the IEM group required postoperative dilatation or reoperation. Patients with IEM fare equally well from laparoscopic Nissen fundoplication as those with normal esophageal motility. There is no merit in tailoring antireflux surgery to the results of preoperative motility tests.     

Laparoscopic antireflux surgery: indications, preoperative evaluation, techniques, and outcomes

BACKGROUND/AIMS: During the past decade, the development of mini-invasive surgery has determined a resurgence in popularity of the antireflux surgery. The purpose of this study is to examine indications, preoperative evaluation, surgical techniques, and outcomes after mini-invasive surgery. METHODOLOGY: From 1996 to 2000, 25 patients with gastroesophageal reflux disease associated to hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24h-pH monitoring, endoscopic evidence of esophagitis, and defective lower esophageal sphincter. Nissen fundoplication was performed in 16 patients with normal esophageal body motility, and 270 degrees posterior fundoplication in 9 patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 130 minutes and mean postoperative hospital stay 5 days. Twenty-four (96%) patients were completely cured of reflux symptoms off all medications. Transient, mild postoperative dysphagia occurred in 3 patients (12%). There was a significant improvement of the results in postoperative esophageal manometry and 24h-pH monitoring. CONCLUSIONS: Despite the fact that few patients were treated by using laparoscopic approach, results are encouraging with less morbidity and great advantages for patients. Precise selection of patients and surgical techniques are essential.     

Concurrent Fluoroscopy and Manometry Reveal Differences in Laparoscopic Nissen and Anterior Fundoplication

A prospective double-blind randomized trial wasinitiated to examine two types of laparoscopicfundoplication (Nissen and anterior). Thirty-twopatients with proven gastroesophageal reflux diseasepresenting for primary laparoscopic antireflux surgerywere randomized to undergo either Nissen fundoplication(N = 13) or anterior hemifundoplication (N = 19).Postoperative fluoroscopic and manometric examinationwas carried out concomitantly. Nissenfundoplication resulted in significantly greaterelevation of resting (33.5 vs 23 mm Hg) and residuallower esophageal sphincter pressures (17 vs 6.5 mm Hg)and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than theanterior partial fundoplication. A smallerradiologically measured sphincter opening diameter wasseen following Nissen fundoplication (9 mm) comparedwith anterior fundoplication (12 mm). Lower esophageal ramppressure correlated weakly (r = 0.37, P = 0.04) withpostoperative dysphagia. It is concluded that the typeof fundoplication performed significantly influences postoperative manometric and video bariumradiology outcomes. The clinical relevance of thisrequires further investigation.     

Gastroesophageal reflux and bronchial responsiveness: correlation and the effect of fundoplication

BACKGROUND: A causal relationship between gastroesophageal reflux (GER) and asthma has been suggested. Should this be the case, one could expect treatment of GER to diminish bronchial sensitivity. There has been a lack of trials evaluating the efficacy of antireflux surgery on airway reactivity. OBJECTIVES: To investigate the correlation between GER and bronchial responsiveness, and to determine the efficacy of Nissen fundoplication on bronchial responsiveness and pulmonary function. METHODS: A methacholine inhalation challenge was performed on 15 consecutive GER patients preoperatively and approximately 5 months after Nissen fundoplication. Airway responsiveness was quantified with a dose-response slope (DRS), calculated by dividing the decrease in FEV(1) (%) with the dose of methacholine administered (micromoles). RESULTS: A positive correlation between the severity of distal esophageal reflux and bronchial responsiveness was found (r = 0.83, p < 0.001). There was an improvement in FEV(1) after fundoplication (p = 0.03). All 3 asthmatic patients participating in the study presented with bronchial hyperresponsiveness (BHR) which improved clearly in all of these patients after fundoplication. This resulted in an apparent trend for DRS to improve when the entire study population was considered (p = 0.12). CONCLUSIONS: According to the current study there seems to be a positive correlation between the severity of distal esophageal reflux and bronchial responsiveness. These data suggest that operative treatment of GER may ameliorate BHR in asthmatic patients. Moreover, the results of the present study suggest that fundoplication may improve pulmonary function in patients with GER.     

Surgical treatment of the non-complicated gastroesophageal reflux: fundoplication without division of the short gastric vessels

BACKGROUND: There is today a significant greater number of laparoscopic antireflux procedures for the surgical treatment of gastroesophageal reflux disease and there are yet controversies about the necessity of division of the short gastric vessels and full mobilization of the gastric fundus to perform an adequate fundoplication. AIM: To verify the results of the surgical treatment of non-complicated gastroesophageal reflux disease performing Rossetti modification of the Nissen fundoplication. Patients and Methods - Fourteen patients were operated consecutively and prospectively (mean age 44.07 years); all had erosive esophagitis without Barrett's endoscopic signals (grade 3, Savary-Miller) and they were submitted to the Rossetti modification of the Nissen fundoplication. Endoscopy, esophageal manometry and pHmetry were performed before the procedure and around 18 months postoperatively. RESULTS: There was no morbidity, transient dysphagia average was 18.42 days; there was no register of dehiscence or displacement of the fundoplication and only one patient revealed a light esophagitis at postoperative endoscopy; the others presented a normal endoscopic view of the distal esophagus. All noticed a marked improvement of preoperative symptoms. Lower esophageal sphincter pressure changed from 5.82 mm Hg (preoperative mean) to 12 mm Hg (postoperative mean); lower esophageal sphincter relaxing pressure, from 0.38 mm Hg to 5.24 mm Hg and DeMeester score, from 16.75 to 0.8. CONCLUSION: Rossetti procedure (fundoplication without division of the short gastric vessels) is an effective surgical method to treat gastroesophageal reflux disease.     

Abnormal acid reflux in asthmatic patients in a region with low GERD prevalence

Background A high prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients has been reported from North America and Europe. However, only a few data from Asia are available. This study evaluated the incidence of abnormal gastroesophageal reflux (GER) in asthmatic patients in Taiwan.Methods Fifty-six consecutive ambulatory patients with clinically stable asthma (41 men and 15 women; age, 57.7 ± 12.4 years; range, 24 to 74 years) were evaluated prospectively. All patients underwent esophagogastroduodenoscopy, esophageal manometry, and 24-h esophageal pH monitoring.Results Twenty-nine patients (51.8%) had abnormal GER, as defined by 24-h esophageal pH monitoring. There were 42 patients without endoscopic evidence of esophagitis, 10 patients with Los Angeles (LA) grade A esophagitis, and 4 patients with LA grade B esophagitis. The esophageal motility function studies revealed 21 patients with normal esophageal motility, 23 patients with ineffective esophageal motility (IEM), and 12 patients with nonspecific esophageal motility disorders other than IEM. Although the lower esophageal sphincter (LES) basal pressure was higher in the patients without GER, the difference was not statistically significant.Conclusions Abnormal GER seems to be a clinically significant problem in asthmatic patients in Taiwan. The most common esophageal motility dysfunction is IEM. However, the status of Helicobacter pylori infection plays no role in abnormal GER.     

Fundoplication wrap disruption: an experimental study in rats.

Antireflux surgery usually gives long lasting control of gastroesophageal reflux disease, but late failures can occur from fundoplication wrap disruption. Disruption presumably occurs when physiological mechanical stresses cause the sutures to pull out of the fundoplication wrap. We hypothesized that complete fundoplications (fundus sutured to fundus) would withstand disruptive forces better than partial fundoplications (fundus sutured to esophagus). Forty-eight rats underwent fundoplication (24 partial and 24 complete). Fundoplication wraps were disrupted by distending the stomach (bursting pressure technique) and by distracting the wrap in a tensiometer (breaking strength technique). Bursting pressures were similar in the partial (103.7 +/- 13.5 mmHg) and complete (100.5 +/- 13.1 mmHg) fundoplication wraps (P = 0.93, not significant). In both groups, all disruptions occurred by sutures tearing through the stomach wall. Breaking strength was also equivalent for the two types of wrap. Partial wraps disrupted at 6.69 +/- 1.49 N and complete wraps disrupted at 6.52 +/- 1.28 N (P = 0.77, not significant). Sutures tore out of the stomach side of the partial wrap in five rats and out of the esophagus in the other seven rats with partial wraps. Disruption occurred by sutures tearing through the stomach in all rats with complete fundoplications. This experimental study in the rat did not show any difference in the ability of partial and complete fundoplication wraps to withstand disruptive forces.     

Objective assessment of gastroesophageal reflux after extended Heller myotomy and total fundoplication for achalasia with the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH)

SUMMARY. This study aims to evaluate by the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII‐pH. MII‐pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII‐pH are warranted to check at a longer follow‐up for the efficacy of this antireflux procedure in achalasic patients.     

Dysphagia and esophageal motor dysfunction in gastroesophageal reflux are corrected by fundoplication

Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction.