Does a patient with a history of Barrett's esophagus, diagnosed several years ago, need an Esophagogastroduodenoscopy (EGD) before undergoing an esophageal manometry study prior to a planned Nissen fundoplication for Gastroesophageal Reflux Disease (GERD)?

EGD Before Manometry in Barrett's Esophagus Patients

Yes, the patient needs an updated EGD before proceeding with esophageal manometry prior to Nissen fundoplication. Given the several-year gap since the last endoscopy and the presence of Barrett's esophagus, current assessment of the Barrett's segment, dysplasia status, and esophageal complications is mandatory before surgical planning.

Why EGD Must Come First

Endoscopy should always be performed to rule out GERD complications before surgery, particularly in patients with known Barrett's esophagus 1. The preoperative evaluation serves multiple critical purposes:

Assessment of Barrett's Progression and Dysplasia

• Upper endoscopy with biopsy is necessary to confirm Barrett's esophagus status, evaluate for dysplasia, assess esophagitis severity, and rule out complications before any antireflux surgery 2
• Barrett's esophagus carries approximately 0.5% annual risk of progression to adenocarcinoma, meaning several years without surveillance creates meaningful cancer risk 1, 3
• The incidence of reflux esophagitis and Barrett's progression increases with time, making outdated endoscopic information inadequate for surgical planning 1

Documentation of Current Anatomy

• All patients considered for antireflux surgery must undergo barium esophagogram to evaluate hernia type, size, and esophageal anatomy, but endoscopy provides complementary mucosal assessment 2
• Document Barrett's length using Prague criteria (C and M measurements) to establish baseline for postoperative surveillance 3
• Esophageal length assessment is crucial for surgical planning, as it identifies potential "short esophagus" requiring lengthening procedures like Collis gastroplasty 2

Exclusion of Contraindications to Surgery

• Endoscopic evaluation is paramount for identification of esophagitis or Barrett epithelium that may alter surgical approach 1
• Detection of high-grade dysplasia or early adenocarcinoma would fundamentally change management from fundoplication to endoscopic resection or ablation 1
• Patients with reflux and esophagitis on examination have 9.9% likelihood of having Barrett's esophagus that may have been missed or progressed since prior endoscopy 4

The Proper Sequence of Preoperative Testing

Step 1: Updated EGD with Biopsies

• Perform endoscopy using high-definition white light endoscopy, preferably with optical chromoendoscopy 1
• Obtain quadrantic biopsies every 2 cm throughout the Barrett's segment using Seattle protocol, plus targeted biopsies of any visible lesions 3
• Ensure patient has been on high-dose PPI therapy for adequate acid suppression during evaluation 1

Step 2: Esophageal Manometry

• High-resolution manometry is mandatory to evaluate esophageal peristaltic function and rule out achalasia before any surgical intervention 2
• Manometry might be useful prior to considering surgery, though there is currently limited evidence about its role compared to pH monitoring 1
• This test identifies esophageal dysmotility that may influence choice between total versus partial fundoplication 1

Step 3: pH-Impedance Monitoring

• 24-hour pH-impedance monitoring is necessary to confirm refractory GERD and document acid exposure patterns before proceeding with surgery 2
• MII-pH monitoring over 24 hours is the best available tool for diagnosis of GERD in the surgical planning context 1

Critical Pitfalls to Avoid

• Do NOT proceed to surgery without proper preoperative physiological testing (manometry and pH monitoring) to confirm diagnosis and rule out alternative pathology 2
• Never assume Barrett's status is unchanged after several years—23.9% of esophageal adenocarcinomas in Barrett's patients are diagnosed within 1 year of a "negative" endoscopy, indicating missed lesions 1
• Avoid relying on outdated endoscopic findings when Barrett's esophagus is present, as dysplasia can develop during the surveillance gap 1
• Do not perform manometry before confirming current mucosal status, as detection of dysplasia or cancer would obviate the need for manometry and redirect management entirely 1

Special Considerations for Barrett's Patients Undergoing Fundoplication

• Surgical treatment may be more effective than medical therapy to modify the natural history of low-grade dysplasia in Barrett's patients, with 93.8% regression rate versus 63.2% with medical therapy alone 5
• The Collis-Nissen fundoplication provides better reflux protection for Barrett's patients than standard Nissen repair, with 90% success at 10 years versus 63% 6
• After fundoplication, Barrett's extension may decrease and lower esophageal sphincter pressure may increase, though the procedure cannot completely eliminate all reflux 7, 8