Does laparoscopic antireflux surgery prevent the occurrence of transient lower esophageal sphincter relaxation? F. Bahmeriz, 1 S. Dutta, 1 C. J. Allen, 2 C. Gill Pottruff, 1 M. Anvari 1 1 Department of Surgery, St. Joseph’s Healthcare, McMaster University, 50 Charlton Avenue East, Hamilton, Ontario, Canada L8N 4A6 2 Department of Medicine, St. Joseph’s Healthcare, McMaster University, 50 Charlton Avenue East, Hamilton, Ontario, Canada L8N 4A6 Received: 6 August 2002/Accepted: 19 December 2002/Online publication: 6 May 2003 Abstract Background: Transient lower esophageal sphincter re- laxation (TLESR) is the most common mechanism un- derlying gastroesophageal reflux disease (GERD), causing 70% to 100% of the reflux episodes in normal subjects and 63% to 74% of the reflux episodes in pa- tients with reflux disease. This study aimed to evaluate the effect of laparoscopic Nissen fundoplication on TLESR in patients with proven GERD. Methods: We prospectively followed 73 consecutive patients(13menand60women;meanage,43.7±1.72 years) with proven diagnosis of GERD and reported TLESRsfoundduringa40-minesophagealmanometric study. These patients had repeat testing 6 months after undergoing laparoscopic Nissen fundoplication. Results: Laparoscopic Nissen fundoplication increased the basal and nadir lower esophageal sphincter (LES) pressure and significantly reduced the number of TLESRsduringthemanometricstudy.Nopatientsafter surgeryexhibitedTLESRwithnadirlessthan2mmHg. However,8ofthe73patients(11%)exhibitedTLESRto a nadir exceeding 50% of basal pressure (mean nadir, 5.0 ± 1.07 mmHg). Conclusions: The number of TLESRs is reduced signif- icantly by antireflux surgery. Even accounting for in- creased basal and nadir pressures, the incidence of TLESR is reduced, suggesting that there may be addi- tional mechanisms involved in this process. Key words: Transient lower esophageal sphincter re- laxation (TLESR) — Laparoscopic fundoplication — Gastroesophagcal reflux disease Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinal disorder in the West, causing symptoms of heartburn and regurgitation in 25% to 30% of the general population. Approximately 10% to 20% of the patients present with complications of GERD. These include esophageal ulceration, stric- ture formation, intestinal metaplasia of the esophageal lining, and pulmonary complications [5, 17, 18, 22, 25]. Although the specific pathophysiology of reflux re- mains elusive [23], transient lower esophageal sphincter relaxation (TLESR) is thought to be the most common mechanism underlying GERD. It represents abrupt de- creasesintheloweresophagealsphincter(LES)pressure to the level of intragastric pressure not initiated by swallowing. In normal subjects, TLESRs account for 70% to100% ofrefluxepisodes,and40% to74% ofsuch episodes in patients with GERD [9, 20, 21]. The effect of open antireflux surgery on TLESR [14, 16, 24] has been examined by a few studies conducted with a small number of patients. These studies have suggested that fundoplication may have two effects: partialreductionintherateofTLESRsandareduction intheproportionofTLESRsaccompaniedbyreflux.So far, no studies have evaluated the effect of laparoscopic Nissen fundoplication (LNF) on the TLESR rate in a large cohort of patients. We prospectively followed 73 patients with documented GERD and TLESR who underwentLNFtodeterminetheeffectofthisprocedure on the incidence of TLESR. Patients and methods Patients We prospectively followed 73 consecutive patients (13 men and 60 women; mean age, 43.7 ± 1.72 years) with a proven preoperative di- agnosis of GERD in a 24-h ambulatory pH study and report our finding of TLESRs on esophageal manometry. The patients also had an upper gastrointestinal endoscopy and GERD symptom score as- sessment. All the patients either had intractable reflux symptoms that were not controlled by medical therapy or did not want to take long- term antireflux medication and were referred for laparoscopic antire- flux surgery. Of the 73 patients, 18 (25%) had a hiatal hernia. No patient had undergone previous gastric or esophageal surgery. It was Correspondence to: M. Anvari Surg Endosc (2003) 17: 1050–1054 DOI: 10.1007/s00464-002-8839-1 Ó Springer-Verlag New York Inc. 2003