Endoscopic Treatment of Post Laparoscopic Sleeve Gastrectomy Fistula : Results From a Multicenter Retrospective Study

Background: High-resolution esophageal manometry (HREM) is the gold standard for evaluation of esophageal motility disorders.However, symptoms rarely occur during a monitored liquid swallow, especially when symptoms are intermittent.Recent literature supports use of provocative HREM protocols to more reliably induce symptoms and assess motility when "under duress."Our protocol involves patients bringing a meal to be eaten while undergoing prolonged monitoring during and after meal ingestion.We hypothesized that this would provoke symptoms and increase diagnostic yield.Aims: The aims of our study were to determine whether 1) the addition of dedicated postprandial monitoring enhanced diagnostic yield in patients with intermittent symptoms, and whether 2) a 30-minute postprandial monitoring period was sufficient to capture symptoms in the majority of referred patients.Methods: Consecutive patients who underwent HREM with postprandial monitoring at a single academic referral center from January to October 2012 were reviewed.Demographics, initial diagnosis, final diagnosis, number of symptoms, and changes in management were recorded.Patients were encouraged to bring a meal of their choice which would be likely to produce symptoms.All patients underwent standard HREM with 10 liquid swallows.The meal was then ingested while the HREM catheter remained in position for 30 minutes.All symptoms were noted.Results: Out of 458 patients who underwent HREM during the study period, 15 patients (mean age= 52.9, range= 25-80, Females=66.7%) were referred specifically for HREM with extended postprandial monitoring.Indications were: refractory belching ( 6), atypical GERD (3), regurgitation (3), and intermittent dysphagia (3).Ten of the 15 patients recorded symptoms (belching, dysphagia or chest pressure) during the 30 minute monitoring period.The number of symptoms provoked ranged from 0 to "innumerable" with a median value of 5. Six of the 15 patients had new manometric findings after meal ingestion, that were not evident when taking only liquid swallows, with subsequent changes in both diagnoses and management.New diagnoses detected with dedicated postprandial monitoring included rumination, supragastric belching, gastric belching, and diffuse esophageal spasm.Conclusion: HREM with extended postprandial monitoring enhanced diagnostic yield as compared to conventional HREM.Postprandial monitoring should be considered in patients with intermittent symptoms such as dysphagia or belching, where symptomatic provocation is desired to assure complete evaluation, or in patients for whom rumination is suspected.Thirty minutes appears to be an adequate duration to allow symptom genesis.Prospective evaluation will help determine which subset of symptoms has highest diagnostic yield with this protocol.