Real-World Diagnostic Gaps in Patients Undergoing Antireflux Surgery: A Retrospective Process-of-Care Analysis

Background Optimal patient selection for antireflux surgery depends on structured preoperative diagnostic evaluation integrating endoscopic, anatomic, and physiologic assessments. Despite international guideline recommendations, the completeness and sequencing of this evaluation in real-world practice remain variable. We aim to identify and characterize diagnostic gaps in the preoperative evaluation of patients undergoing antireflux surgery, focusing on absence or suboptimal timing of key investigations relative to a prespecified minimum diagnostic dataset. Methods We conducted a retrospective process-of-care analysis of consecutive adult patients who underwent antireflux surgery at a tertiary academic center. A minimum preoperative diagnostic dataset was defined a priori and included upper endoscopy, contrast esophagram, and esophageal manometry, consistent with contemporary recommendations. Additional investigations, including cross-sectional imaging and gastric emptying studies, were considered indication-based. Diagnostic gaps were defined as absence of a minimum dataset component prior to surgery or completion of that component only postoperatively. Analyses were descriptive. Results The cohort comprised 64 patients. Preoperative upper endoscopy was available in 47 patients (73%), contrast esophagram in 61 (95%), and esophageal manometry in 18 (28%). Completion of the full minimum diagnostic dataset prior to surgery occurred in 18 patients (28%). Overall, 46 patients (72%) proceeded to surgery with at least one diagnostic gap; 29 (45%) had a single gap and 17 (27%) had multiple gaps. Esophageal manometry was the most frequent missing component, absent preoperatively in 46 patients (72%). Sequencing-related gaps, with minimum dataset investigations completed only after surgery, were observed in 9 patients (14%). Among patients presenting with dysphagia (n = 17), preoperative manometry was absent in 11 (65%). Conclusion In this real-world cohort, antireflux surgery was frequently undertaken without a complete or optimally sequenced preoperative diagnostic evaluation. These findings highlight system-level opportunities to improve diagnostic pathway consistency and auditability while preserving clinical flexibility.