A 50-year-old woman presents with refractory GERD and 5 cm hiatus hernia. High-resolution manometry shows hypotensive LES (4 mmHg) with 95% ineffective esophageal motility. Which finding on preoperative workup would most influence the surgical approach to antireflux surgery?

• A DeMeester score > 14 on ambulatory pH monitoring
• B Distal esophageal amplitude <30 mmHg (ineffective esophageal motility)
• C Hiatus hernia size > 3 cm on barium swallow
• D Severely impaired esophageal peristaltic amplitude with pan-esophageal pressurization ✓

Explanation

Severely impaired esophageal motility—specifically pan-esophageal pressurization or aperistalsis consistent with achalasia or absent contractility—would favor a partial fundoplication (Toupet 270° posterior or Dor 180° anterior) rather than the standard 360° Nissen fundoplication, to avoid dysphagia from an obstructive wrap. Ineffective esophageal motility (amplitude <30 mmHg in >50% swallows) alone is less convincing evidence against Nissen in current guidelines. DeMeester score >14 confirms pathological reflux. Hiatus hernia size informs technical repair but not wrap type. Pan-esophageal pressurization or aperistalsis on high-resolution manometry (Chicago Classification v4.0) is the key contraindication to complete wrap.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.