Therefore, not only the high postoperative use of ARM is questionable and often incorrect, but also it may not promotion information be a reliable and trustworthy tool for the evaluation of surgical outcome. 4.3. Objective Evaluation of the Esophagus In general, objective outcome measures, probably the better way to evaluate the outcome, are not used frequently, especially in the long-term followup, due to the difficulty of the patients to accept uncomfortable procedures, and this consequently brings a less complete followup. Usually, postoperative objective testing is recommended in presence of persistent or recurrent symptoms after LARS and not in asymptomatic patients, which is realistic in an era of cost containment.

However, this approach may not be appropriate, since many symptomatic patients do not show any pathologic reflux at 24 pH-metry; conversely, asymptomatic patient may have significant pathological reflux [19]. 4.4. Endoscopy Upper GI endoscopy was carried out in a low percentage of patient’s population and failed to provide any useful critical information. Relationship with symptoms was poor, and the evaluation and grading of esophageal lesions (when present) were found to be extremely subjective. As a consequence, ��standard�� endoscopic examination is unlikely to influence postoperative management. 4.5. Esophageal Manometry While a significant postoperative increase of LES pressure has been found in successful, asymptomatic patients [47], other investigations failed to show any significant difference in pressure increase between symptomatic and asymptomatic patients [48].

Moreover, no correlation has been found between postoperative LES pressure and symptoms or 24 hour pH-metry results [17]. Taking into account the inconsistent manometric findings and the difficult acceptance of the procedure by the patients, it is hard to propose it as a regular and trustable postoperative test, its role being secondary to esophageal pH recording in symptomatic patients. 4.6. 24 Hour Esophageal pH-metry In the papers examined, postoperative 24-hour pH-metry has been the most frequently performed objective test, mainly to identify patients with true recurrent gastroesophageal reflux. The reproducibility of 24-hour pH monitoring is essential to make it reliable. Actually, a concordance rate of 96% in repeated test was recently reported [40]. Ideally, patients with recurring symptoms should undergo a 24-hour pH probe study for an objective evaluation and quantitation of acidic reflux. We do not feel that such test should be recommended Brefeldin_A postoperatively on a routine basis. Indeed, finding a positive test in an asymptomatic patient would be challenging due to the lack of established guidelines in this clinical setting.