I read with great interest the article by Granderath et al1 concerning the impact of laparoscopic Nissen fundoplication with prosthetic hiatal closure on esophageal body motility. I have several questions and comments:
What was the length of the Barrett mucosa?
The size of the mesh that they used, according to Figure 2, is meaningless, in my personal opinion. It is so small that it is hard to believe any real beneficial effect would result. In the nonmesh group, some patients even needed 1 suture to close the hiatus.
I am surprised that the total length of the lower esophageal sphincter was only 20 mm in each group. In my large experience over 6000 manometric studies in patients with pathologic gastroesophageal reflux, a total length near or less than 20 mm is seen in no more than one-third of the patients.
The mean resting pressure of lower esophageal sphincter was near 3 to 4 mm Hg in each group. What is the resting pressure in their control subjects? A lower esophageal sphincter pressure of less than 6 mm Hg (incompetent sphincter) is seen in no more than 20% to 30% of patients who are candidates for surgery, even with Barrett esophagus. In the great majority of published reports, including several of our studies, this resting pressure before surgery is near 6 to 8 mm Hg. What is the explanation for such a low pressure, an almost nonexistent pressure in their groups?
How can you measure percentage of relaxation of lower esophageal sphincter if your resting pressure is 3 mm Hg? How can you detect manometrically a reduction from 3 to 0 mm Hg? I must confess that for me it is almost impossible after performing so many studies.
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