Surgical physiology of esophagogastric junction. Selective testing is effective; some problems remain elusive

When evaluating foregut symptoms which may originate from many sites, accurate diagnosis must be achieved by cost-effective and efficient diagnostic methods. Since all tests cannot be done routinely, invasive tests are mandatory only when the diagnosis is uncertain; testing which confirms the obvious is overly expensive and superfluous. This report describes “selective” preoperative diagnostic testing for patients with heartburn and dysphagia; endoscopy was used always, but radiography, manometry, and pH testing were done selectively. Hiatus hernia remains an elusive entity which resists easy definition. Methods: A total of 273 patients operations (185 with gastroesophageal reflux disease (GERD) and 88 with achalasia (ACHA) of the esophagus) were operated upon during a 15 year period. All heartburn patients had endoscopy; if erosive esophagitis was present and symptoms responded to medical treatment the diagnosis of GERD was made; manometry and pH studies were performed selectively. Esophagrams or other special X-Rays (spiral tomography) were performed often, but selectively, in preoperative patients and less commonly in postoperative patients. When indicated, fundoplication was performed for GERD and transabdominal cardiomyotomy with fundoplication for ACHA. Results (Tables 1, 2): Endoscopy was performed in all patients. Motility examinations (n = 248) and pH studies (n = 175) were helpful in defining operative candidates; 95% of GERD and ACHA operations were effective, and postoperative hiatus hernia or wrap disruption occurred rarely (2%). ACHA patients had minimal reflux, and one had reoperation for extrinsic stricture at the gastoesophageal junction. Unexpected hiatus hernia was found in 8–10% of both groups. Conclusions: Clinical judgment supported by selective diagnostic testing in GERD and ACHA effectively identified operative candidates. The role of hiatus hernia in causing symptoms in individual patients is largely unknown at present; further, there is no reliable noninvasive way of estimating the size of hernia in a single patient.