{"paper_id":"0b4df880-451f-441d-b9fa-493a07479e2b","body_text":"Real-World Diagnostic Gaps in Patients Undergoing Antireflux Surgery: A Retrospective Process-of-Care Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Real-World Diagnostic Gaps in Patients Undergoing Antireflux Surgery: A Retrospective Process-of-Care Analysis Omran AlDandan, Dhuha Boumarah, Saeed Alshomimi, Hassan AlSaleem, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8588836/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract 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. Antireflux surgery gastroesophageal reflux disease diagnostic gaps preoperative Introduction Antireflux surgery is an established treatment option for selected patients with gastroesophageal reflux disease (GERD), particularly those with refractory symptoms, anatomic abnormalities, or intolerance to long-term medical therapy. Accurate preoperative characterization of esophageal anatomy and physiology is central to appropriate patient selection, operative planning, and minimization of postoperative complications such as dysphagia or persistent reflux [1–2]. Professional society guidelines and multidisciplinary consensus statements consistently emphasize the importance of objective diagnostic testing prior to antireflux surgery, typically incorporating upper endoscopy, contrast esophagram, and esophageal manometry [1–2,6]. These investigations provide complementary information on mucosal disease, anatomic configuration, and esophageal motor function. Despite broad agreement on these principles, real-world diagnostic pathways often evolve pragmatically, influenced by referral patterns, symptom-driven testing, institutional culture, and access to physiologic testing [7]. Most published literature in this field focuses on surgical outcomes, comparative effectiveness of operative techniques, or the predictive value of individual diagnostic tests. In contrast, fewer studies have examined preoperative evaluation as a process of care , specifically whether patients reach surgery with a diagnostically complete and appropriately sequenced workup. Understanding such process-level gaps is essential for quality improvement, pathway standardization, and auditability, independent of operative outcomes or individual clinician judgment. This analysis represents a focused process-of-care component of a broader institutional effort to characterize and standardize GERD surgical evaluation. The objective of this study was to identify and describe diagnostic gaps in preoperative evaluation using a prespecified minimum diagnostic dataset and a system-focused analytic framework. Methods Study Design and Population This retrospective process-of-care analysis included consecutive adult patients who underwent antireflux surgery for suspected GERD at a tertiary academic medical center over the same study period as a companion practice-profiling analysis of this cohort. Institutional review board approval was obtained with a waiver of informed consent. Definition of Minimum Diagnostic Dataset A minimum preoperative diagnostic dataset was defined a priori based on contemporary guideline recommendations and included: Upper endoscopy to evaluate mucosal disease, complications of reflux, and alternative diagnoses. Contrast esophagram to assess esophageal anatomy, hiatal hernia, and swallowing dynamics. Esophageal manometry to characterize esophageal motor function and exclude major motility disorders relevant to operative planning. Cross-sectional imaging and gastric emptying studies were classified as indication-based investigations and were not considered required components of the minimum dataset [2]. Data Collection Electronic medical records were reviewed to determine whether each minimum dataset component was performed and whether it was completed within the preoperative window. Timing was categorized as preoperative or postoperative relative to the date of surgery. Presence of dysphagia at presentation was recorded to contextualize physiologic testing decisions. Definition of Diagnostic Gaps A diagnostic gap was defined as: Absence of a minimum dataset component prior to surgery, or Completion of a minimum dataset component only after surgery, thereby limiting its contribution to preoperative decision-making. Patients were categorized by number of gaps (none, single, or multiple). Statistical Analysis Statistical analysis was descriptive. Categorical variables are presented as counts and percentages. No hypothesis testing or outcome-association analyses were performed, consistent with the process-of-care focus of the study. Results A total of 64 consecutive adult patients underwent antireflux surgery and comprised the study cohort. Preoperative upper endoscopy was available in 47 patients (73%), contrast esophagram in 61 patients (95%), and esophageal manometry in 18 patients (28%). Completion of all three components of the minimum diagnostic dataset prior to surgery was observed in 18 patients (28%). Overall, 46 patients (72%) proceeded to surgery with at least one diagnostic gap. A single gap was identified in 29 patients (45%), while 17 patients (27%) demonstrated multiple concurrent gaps. Esophageal manometry represented the most frequent missing component, absent preoperatively in 46 patients (72%). Sequencing-related diagnostic gaps were observed in 9 patients (14%), in whom one or more minimum dataset investigations were completed only after surgery. Among patients presenting with dysphagia (n = 17), absence of documented preoperative esophageal manometry was observed in 11 patients (65% Discussion This retrospective process-of-care analysis demonstrates that a substantial proportion of patients undergoing antireflux surgery proceeded without completion of a prespecified minimum diagnostic dataset or with suboptimal sequencing of key investigations. Importantly, this work does not assess surgical outcomes or adjudicate individual clinical decisions. Instead, it characterizes diagnostic completeness and timing as system-level properties, an aspect often assumed in guideline discussions but infrequently quantified in real-world practice [1–2]. A key contribution of this study is the explicit differentiation between missingness of diagnostic tests and sequencing failure, where investigations are performed only after surgery. While many prior surgical series focus on whether tests were performed at all, the timing of those tests relative to operative decision-making is equally important from a quality and audit perspective. Investigations completed postoperatively may reflect legitimate clinical needs, but they may also represent missed opportunities for preoperative risk stratification and operative tailoring [5–6]. The most frequent diagnostic gap identified in this cohort was absence of preoperative esophageal manometry. This finding aligns with prior reports describing heterogeneity in the use of physiologic testing across institutions and referral pathways [5,7]. Contemporary consensus statements, including the ICARUS and Lyon consensus frameworks, emphasize that the primary role of manometry before antireflux surgery is not to confirm reflux but to exclude major motility disorders and inform surgical planning [2,6]. Accordingly, omission of manometry has implications beyond diagnostic confirmation alone. At the same time, interpretation of absent manometry requires nuance. Current guidelines acknowledge that unequivocal endoscopic evidence of GERD—such as severe erosive esophagitis or established Barrett’s esophagus—may obviate the need for additional reflux confirmation testing in selected patients [1–2]. In such cases, clinicians may reasonably prioritize definitive management. However, even when reflux is established by mucosal findings, esophageal motor function remains clinically relevant to operative strategy and postoperative symptom risk. From a pathway perspective, omission of manometry in this context represents a gap in physiologic characterization, not necessarily inappropriate care. Explicit documentation of the rationale for deferring physiologic testing would enhance auditability and interpretability of such deviations. The dysphagia subgroup provides a particularly salient quality signal. Dysphagia is both a preoperative symptom that may indicate alternative pathology and a postoperative complication that surgeons seek to minimize. Multiple guidelines emphasize that dysphagia should prompt careful physiologic assessment prior to antireflux surgery [6]. In this cohort, the high frequency of absent preoperative manometry among patients presenting with dysphagia highlights a pragmatic target for pathway refinement that aligns with both clinical intuition and guideline principles. This study is limited by its retrospective, single-center design. Documentation-based assessment may underestimate investigations performed externally. Surgical outcomes were intentionally not analyzed, as the objective was to evaluate diagnostic processes rather than procedural effectiveness. However, the novelty of this work lies in framing preoperative evaluation as a minimum dataset compliance and sequencing problem, quantified at the cohort level and presented without outcome linkage or clinician attribution. By isolating the process-of-care layer, this study provides a clean baseline for future pathway implementation and outcome-linked analyses. Moreover, it supports the development of indication-aware diagnostic pathways, in which the minimum dataset is required by default and deviations are explicitly justified and documented. Conclusion Diagnostic gaps in the preoperative evaluation of patients undergoing antireflux surgery are common in real-world practice, particularly with respect to physiologic testing and investigation sequencing. Recognition of these gaps supports development of standardized, indication-aware diagnostic pathways to improve preoperative decision-making while maintaining necessary clinical flexibility. Future pathway refinement may benefit from explicit documentation of rationale when physiologic testing is deferred, allowing differentiation between justified omission and unintentional diagnostic gaps. Declarations Data Availability De-identified patient-level data underlying this study are available from the corresponding author upon reasonable request, subject to institutional data governance approval. Ethics approval and consent to participate Ethical approval was obtained from the Institutional Review Board Committee at Imam Abdulrahman bin Faisal University, King Fahd Hsopital of the University, Dammam, Saudi Arabia. Given the retrospective nature of the study and the use of anonymized data, the requirement for informed consent to participate was waived by the Ethical Committee. Consent for publication Consent for publication was waived by the Ethics Committee due to the retrospective design of the study and the use of de-identified data. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality and ethical considerations, but are available from the corresponding author on reasonable request and with permission from the relevant Ethics Committee. Competing interests None Funding None Authors' contributions OA and DB conceived and designed the study, performed the data analysis, and drafted the manuscript. SA and HA contributed to data collection and data interpretation. MA assisted with data collection and critically revised the manuscript. HSA contributed to study design, data analysis, and critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work. Acknowledgements None Clinical trial number Not applicable References Katz PO, Dunbar KB, Schnoll‑Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117(1):27‑56. doi:10.14309/ajg.0000000000001538. Gyawali CP, Yadlapati R, Fass R, Katzka D, Pandolfino J, Savarino E, et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2024;73(2):361‑71. doi:10.1136/gutjnl‑2023‑330616. Slater BJ, Collings A, Dirks R, Gould JC, Qureshi AP, Juza R, et al. Multi‑society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD). Surg Endosc. 2023;37(2):781‑806. doi:10.1007/s00464‑022‑09817‑3. Alzahrani MA, Alqaraawi AM, Alzubide SR, Abufarhaneh E, Alkhowaiter SS, Alsulaimi M, et al. Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of gastroesophageal reflux disease. Saudi J Gastroenterol. 2024;30(6):353‑68. doi:10.4103/sjg.sjg_82_24. Yodice M, Mignucci A, Shah V, Ashley C, Tadros M. Preoperative physiological esophageal assessment for antireflux surgery: a guide for surgeons on high‑resolution manometry and pH testing. World J Gastroenterol. 2021;27(16):1751‑69. doi:10.3748/wjg.v27.i16.1751. Pauwels A, Boecxstaens V, Andrews CN, Attwood SE, Berrisford R, Bisschops R, et al. How to select patients for antireflux surgery? The ICARUS guidelines. Gut. 2019;68(11):1928‑41. doi:10.1136/gutjnl‑2019‑318260. Schlottmann F, Herbella FAM, Patti MG. Surgical treatment of gastroesophageal reflux disease: current controversies. World J Surg. 2017;41(7):1683‑90. doi:10.1007/s00268‑017‑3936‑5. Phillips HR, Kamboj AK, Leggett CL. Diagnosis and management of gastroesophageal reflux disease: a concise review for clinicians. Mayo Clin Proc. 2025;100(5):882‑9. doi:10.1016/j.mayocp.2025.01.007. Dunn CP, Eriksson SE, Jobe BA, Ayazi S. Endoscopy and antireflux surgery: a technical review of pre‑ and postoperative evaluation and recognizing patterns of failure. Foregut. 2023;3(4):482‑92. doi:10.1177/26345161231174246. Gensthaler L, Schoppmann SF. New developments in antireflux surgery: where are we now? Visc Med. 2024;40(5):250‑55. doi:10.1159/000538117. Nagarajan A, Goutham M, Jagtiani M, Pore N, Sheth H, Raje D. Accuracy of barium swallow and pH manometry in pre‑operative assessment for antireflux surgery. Br J Surg. 2023;110(Suppl 8):znad348.120. doi:10.1093/bjs/znad348.120. Tables Table 1. Completion of Minimum Preoperative Diagnostic Dataset Investigation Preoperative, n (%) Postoperative only, n (%) Upper endoscopy 47 (73) — Contrast esophagram 61 (95) — Esophageal manometry 18 (28) 9 (14) Table 2. Diagnostic Gaps in Preoperative Evaluation Postoperative-only investigations were considered sequencing-related diagnostic gaps, as they did not inform preoperative surgical decision-making Diagnostic category n (%) Complete minimum dataset (no gaps) 18 (28) ≥1 diagnostic gap 46 (72) Single diagnostic gap 29 (45) Multiple diagnostic gaps (≥2 components missing) 17 (27) Dysphagia with absent preoperative manometry 11 / 17 (65) Diagnostic gaps were defined as absence of a minimum dataset component prior to surgery or completion of that component only after surgery Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 04 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 30 Mar, 2026 Editor invited by journal 06 Feb, 2026 Editor assigned by journal 04 Feb, 2026 Submission checks completed at journal 04 Feb, 2026 First submitted to journal 13 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8588836\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":614864721,\"identity\":\"e657f329-2c3b-41a3-b6ef-0d218398e39d\",\"order_by\":0,\"name\":\"Omran AlDandan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Imam Abdulrahman Bin Faisal University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Omran\",\"middleName\":\"\",\"lastName\":\"AlDandan\",\"suffix\":\"\"},{\"id\":614864722,\"identity\":\"59ba9539-9f32-4d0c-b784-1937584e55e4\",\"order_by\":1,\"name\":\"Dhuha Boumarah\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYBACewYeKEuC+cABMOMAAS2GDXAtbAnEaTE4ANfCY8BAnJbbvQcf8+bY5fPP7vl44GcbgxzfjQTmDz/wablzLtmYd1uy5Yw7Zzcc7G1jMJa8kcAm2YNPy40cM2nebcwGDDdyNxzgbWNI3ADUAg8TPFrqDeRv5Dw4+LeNoR6ohfnjH8JaDhsAGQyHgbYkGNxIYJDGZ4vhjLxkw7nbjhsY3kgzOCxzTsJw5pmHbdIyeLTYS+QefPB2W7WB3I3kxx/flNnI8x1PPvzxDR4t6EACiBkbSNAwCkbBKBgFowAbAADJcVOuyaVaagAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Imam Abdulrahman Bin Faisal University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Dhuha\",\"middleName\":\"\",\"lastName\":\"Boumarah\",\"suffix\":\"\"},{\"id\":614864723,\"identity\":\"b1d37c1d-3b96-4e8d-982b-d0789f2d9948\",\"order_by\":2,\"name\":\"Saeed Alshomimi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Imam Abdulrahman Bin Faisal University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Saeed\",\"middleName\":\"\",\"lastName\":\"Alshomimi\",\"suffix\":\"\"},{\"id\":614864724,\"identity\":\"d314a885-cb89-4699-843d-8818431637c2\",\"order_by\":3,\"name\":\"Hassan AlSaleem\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Imam Abdulrahman Bin Faisal University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hassan\",\"middleName\":\"\",\"lastName\":\"AlSaleem\",\"suffix\":\"\"},{\"id\":614864725,\"identity\":\"c8c1a919-5830-4a21-af78-35844815280d\",\"order_by\":4,\"name\":\"Mariam AlQurashi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Imam Abdulrahman Bin Faisal University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mariam\",\"middleName\":\"\",\"lastName\":\"AlQurashi\",\"suffix\":\"\"},{\"id\":614864726,\"identity\":\"809c74fa-3e4c-47b9-842f-2f2ebb9145a3\",\"order_by\":5,\"name\":\"Hind AlSaif\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Imam Abdulrahman Bin Faisal University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hind\",\"middleName\":\"\",\"lastName\":\"AlSaif\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-01-13 07:53:19\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8588836/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8588836/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":106415070,\"identity\":\"d969062e-61b9-4d45-9616-83a2d5adab0c\",\"added_by\":\"auto\",\"created_at\":\"2026-04-08 10:32:43\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":536777,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8588836/v1/3d1bed32-d8cd-47fc-aed7-f1229008edf9.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Real-World Diagnostic Gaps in Patients Undergoing Antireflux Surgery: A Retrospective Process-of-Care Analysis\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eAntireflux surgery is an established treatment option for selected patients with gastroesophageal reflux disease (GERD), particularly those with refractory symptoms, anatomic abnormalities, or intolerance to long-term medical therapy. Accurate preoperative characterization of esophageal anatomy and physiology is central to appropriate patient selection, operative planning, and minimization of postoperative complications such as dysphagia or persistent reflux [1–2].\\u003c/p\\u003e\\n\\u003cp\\u003eProfessional society guidelines and multidisciplinary consensus statements consistently emphasize the importance of objective diagnostic testing prior to antireflux surgery, typically incorporating upper endoscopy, contrast esophagram, and esophageal manometry [1–2,6]. These investigations provide complementary information on mucosal disease, anatomic configuration, and esophageal motor function. Despite broad agreement on these principles, real-world diagnostic pathways often evolve pragmatically, influenced by referral patterns, symptom-driven testing, institutional culture, and access to physiologic testing [7].\\u003c/p\\u003e\\n\\u003cp\\u003eMost published literature in this field focuses on surgical outcomes, comparative effectiveness of operative techniques, or the predictive value of individual diagnostic tests. In contrast, fewer studies have examined preoperative evaluation as a\\u003cstrong\\u003e\\u0026nbsp;\\u003cstrong\\u003eprocess of care\\u003c/strong\\u003e,\\u003c/strong\\u003e specifically whether patients reach surgery with a diagnostically complete and appropriately sequenced workup. Understanding such process-level gaps is essential for quality improvement, pathway standardization, and auditability, independent of operative outcomes or individual clinician judgment.\\u003c/p\\u003e\\n\\u003cp\\u003eThis analysis represents a focused process-of-care component of a broader institutional effort to characterize and standardize GERD surgical evaluation. The objective of this study was to identify and describe diagnostic gaps in preoperative evaluation using a prespecified minimum diagnostic dataset and a system-focused analytic framework.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003ch3\\u003eStudy Design and Population\\u003c/h3\\u003e\\n\\u003cp\\u003eThis retrospective process-of-care analysis included consecutive adult patients who underwent antireflux surgery for suspected GERD at a tertiary academic medical center over the same study period as a companion practice-profiling analysis of this cohort. Institutional review board approval was obtained with a waiver of informed consent.\\u003c/p\\u003e\\n\\u003ch3\\u003eDefinition of Minimum Diagnostic Dataset\\u003c/h3\\u003e\\n\\u003cp\\u003eA minimum preoperative diagnostic dataset was defined a priori based on contemporary guideline recommendations and included:\\u003c/p\\u003e\\n\\u003col\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eUpper endoscopy\\u003c/strong\\u003e to evaluate mucosal disease, complications of reflux, and alternative diagnoses.\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eContrast esophagram\\u003c/strong\\u003e to assess esophageal anatomy, hiatal hernia, and swallowing dynamics.\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cstrong\\u003eEsophageal manometry\\u003c/strong\\u003e to characterize esophageal motor function and exclude major motility disorders relevant to operative planning.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003eCross-sectional imaging and gastric emptying studies were classified as indication-based investigations and were not considered required components of the minimum dataset [2].\\u003c/p\\u003e\\n\\u003ch3\\u003eData Collection\\u003c/h3\\u003e\\n\\u003cp\\u003eElectronic medical records were reviewed to determine whether each minimum dataset component was performed and whether it was completed within the preoperative window. Timing was categorized as preoperative or postoperative relative to the date of surgery. Presence of dysphagia at presentation was recorded to contextualize physiologic testing decisions.\\u003c/p\\u003e\\n\\u003ch3\\u003eDefinition of Diagnostic Gaps\\u003c/h3\\u003e\\n\\u003cp\\u003eA diagnostic gap was defined as:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eAbsence of a minimum dataset component prior to surgery, or\\u003c/li\\u003e\\n \\u003cli\\u003eCompletion of a minimum dataset component only after surgery, thereby limiting its contribution to preoperative decision-making.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003ePatients were categorized by number of gaps (none, single, or multiple).\\u003c/p\\u003e\\n\\u003ch3\\u003eStatistical Analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eStatistical analysis was descriptive. Categorical variables are presented as counts and percentages. No hypothesis testing or outcome-association analyses were performed, consistent with the process-of-care focus of the study.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 64 consecutive adult patients underwent antireflux surgery and comprised the study cohort.\\u003c/p\\u003e\\n\\u003cp\\u003ePreoperative upper endoscopy was available in 47 patients (73%), contrast esophagram in 61 patients (95%), and esophageal manometry in 18 patients (28%). Completion of all three components of the minimum diagnostic dataset prior to surgery was observed in 18 patients (28%).\\u003c/p\\u003e\\n\\u003cp\\u003eOverall, 46 patients (72%) proceeded to surgery with at least one diagnostic gap. A single gap was identified in 29 patients (45%), while 17 patients (27%) demonstrated multiple concurrent gaps. Esophageal manometry represented the most frequent missing component, absent preoperatively in 46 patients (72%).\\u003c/p\\u003e\\n\\u003cp\\u003eSequencing-related diagnostic gaps were observed in 9 patients (14%), in whom one or more minimum dataset investigations were completed only after surgery. Among patients presenting with dysphagia (n = 17), absence of documented preoperative esophageal manometry was observed in 11 patients (65%\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis retrospective process-of-care analysis demonstrates that a substantial proportion of patients undergoing antireflux surgery proceeded without completion of a prespecified minimum diagnostic dataset or with suboptimal sequencing of key investigations. Importantly, this work does not assess surgical outcomes or adjudicate individual clinical decisions. Instead, it characterizes diagnostic completeness and timing as system-level properties, an aspect often assumed in guideline discussions but infrequently quantified in real-world practice [1–2].\\u003c/p\\u003e\\n\\u003cp\\u003eA key contribution of this study is the explicit differentiation between missingness of diagnostic tests and sequencing failure, where investigations are performed only after surgery. While many prior surgical series focus on whether tests were performed at all, the timing of those tests relative to operative decision-making is equally important from a quality and audit perspective. Investigations completed postoperatively may reflect legitimate clinical needs, but they may also represent missed opportunities for preoperative risk stratification and operative tailoring [5–6].\\u003c/p\\u003e\\n\\u003cp\\u003eThe most frequent diagnostic gap identified in this cohort was absence of preoperative esophageal manometry. This finding aligns with prior reports describing heterogeneity in the use of physiologic testing across institutions and referral pathways [5,7]. Contemporary consensus statements, including the ICARUS and Lyon consensus frameworks, emphasize that the primary role of manometry before antireflux surgery is not to confirm reflux but to exclude major motility disorders and inform surgical planning [2,6]. Accordingly, omission of manometry has implications beyond diagnostic confirmation alone.\\u003c/p\\u003e\\n\\u003cp\\u003eAt the same time, interpretation of absent manometry requires nuance. Current guidelines acknowledge that unequivocal endoscopic evidence of GERD—such as severe erosive esophagitis or established Barrett’s esophagus—may obviate the need for additional reflux confirmation testing in selected patients [1–2]. In such cases, clinicians may reasonably prioritize definitive management. However, even when reflux is established by mucosal findings, esophageal motor function remains clinically relevant to operative strategy and postoperative symptom risk. From a pathway perspective, omission of manometry in this context represents a gap in physiologic characterization, not necessarily inappropriate care. Explicit documentation of the rationale for deferring physiologic testing would enhance auditability and interpretability of such deviations.\\u003c/p\\u003e\\n\\u003cp\\u003eThe dysphagia subgroup provides a particularly salient quality signal. Dysphagia is both a preoperative symptom that may indicate alternative pathology and a postoperative complication that surgeons seek to minimize. Multiple guidelines emphasize that dysphagia should prompt careful physiologic assessment prior to antireflux surgery [6]. In this cohort, the high frequency of absent preoperative manometry among patients presenting with dysphagia highlights a pragmatic target for pathway refinement that aligns with both clinical intuition and guideline principles.\\u003c/p\\u003e\\n\\u003cp\\u003eThis study is limited by its retrospective, single-center design. Documentation-based assessment may underestimate investigations performed externally. Surgical outcomes were intentionally not analyzed, as the objective was to evaluate diagnostic processes rather than procedural effectiveness. However, the novelty of this work lies in framing preoperative evaluation as a minimum dataset compliance and sequencing problem, quantified at the cohort level and presented without outcome linkage or clinician attribution. By isolating the process-of-care layer, this study provides a clean baseline for future pathway implementation and outcome-linked analyses. Moreover, it supports the development of indication-aware diagnostic pathways, in which the minimum dataset is required by default and deviations are explicitly justified and documented.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eDiagnostic gaps in the preoperative evaluation of patients undergoing antireflux surgery are common in real-world practice, particularly with respect to physiologic testing and investigation sequencing. Recognition of these gaps supports development of standardized, indication-aware diagnostic pathways to improve preoperative decision-making while maintaining necessary clinical flexibility. Future pathway refinement may benefit from explicit documentation of rationale when physiologic testing is deferred, allowing differentiation between justified omission and unintentional diagnostic gaps.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eData Availability\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDe-identified patient-level data underlying this study are available from the corresponding author upon reasonable request, subject to institutional data governance approval.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval was obtained from the Institutional Review Board Committee at Imam Abdulrahman bin Faisal University, King Fahd Hsopital of the University, Dammam, Saudi Arabia. Given the retrospective nature of the study and the use of anonymized data, the requirement for informed consent to participate was waived by the Ethical Committee.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication was waived by the Ethics Committee due to the retrospective design of the study and the use of de-identified data.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality and ethical considerations, but are available from the corresponding author on reasonable request and with permission from the relevant Ethics Committee.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNone\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNone\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors' contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eOA and DB conceived and designed the study, performed the data analysis, and drafted the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eSA and HA contributed to data collection and data interpretation.\\u003c/p\\u003e\\n\\u003cp\\u003eMA assisted with data collection and critically revised the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eHSA contributed to study design, data analysis, and critical revision of the manuscript for important intellectual content.\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors read and approved the final manuscript and agree to be accountable for all aspects of the work.\\u003cstrong\\u003e\\u003cbr\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNone\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eClinical trial number\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eKatz PO, Dunbar KB, Schnoll‑Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022;117(1):27‑56. doi:10.14309/ajg.0000000000001538.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eGyawali CP, Yadlapati R, Fass R, Katzka D, Pandolfino J, Savarino E, et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2024;73(2):361‑71. doi:10.1136/gutjnl‑2023‑330616.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eSlater BJ, Collings A, Dirks R, Gould JC, Qureshi AP, Juza R, et al. Multi‑society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD). Surg Endosc. 2023;37(2):781‑806. doi:10.1007/s00464‑022‑09817‑3.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eAlzahrani MA, Alqaraawi AM, Alzubide SR, Abufarhaneh E, Alkhowaiter SS, Alsulaimi M, et al. Saudi Gastroenterology Association consensus on the clinical care pathway for the diagnosis and treatment of gastroesophageal reflux disease. Saudi J Gastroenterol. 2024;30(6):353‑68. doi:10.4103/sjg.sjg_82_24.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eYodice M, Mignucci A, Shah V, Ashley C, Tadros M. Preoperative physiological esophageal assessment for antireflux surgery: a guide for surgeons on high‑resolution manometry and pH testing. World J Gastroenterol. 2021;27(16):1751‑69. doi:10.3748/wjg.v27.i16.1751.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003ePauwels A, Boecxstaens V, Andrews CN, Attwood SE, Berrisford R, Bisschops R, et al. How to select patients for antireflux surgery? The ICARUS guidelines. Gut. 2019;68(11):1928‑41. doi:10.1136/gutjnl‑2019‑318260.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eSchlottmann F, Herbella FAM, Patti MG. Surgical treatment of gastroesophageal reflux disease: current controversies. World J Surg. 2017;41(7):1683‑90. doi:10.1007/s00268‑017‑3936‑5.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003ePhillips HR, Kamboj AK, Leggett CL. Diagnosis and management of gastroesophageal reflux disease: a concise review for clinicians. Mayo Clin Proc. 2025;100(5):882‑9. doi:10.1016/j.mayocp.2025.01.007.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eDunn CP, Eriksson SE, Jobe BA, Ayazi S. Endoscopy and antireflux surgery: a technical review of pre‑ and postoperative evaluation and recognizing patterns of failure. Foregut. 2023;3(4):482‑92. doi:10.1177/26345161231174246.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eGensthaler L, Schoppmann SF. New developments in antireflux surgery: where are we now? Visc Med. 2024;40(5):250‑55. doi:10.1159/000538117.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003eNagarajan A, Goutham M, Jagtiani M, Pore N, Sheth H, Raje D. Accuracy of barium swallow and pH manometry in pre‑operative assessment for antireflux surgery. Br J Surg. 2023;110(Suppl 8):znad348.120. doi:10.1093/bjs/znad348.120.\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTable 1. Completion of Minimum Preoperative Diagnostic Dataset\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"3\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eInvestigation\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePreoperative, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePostoperative only, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUpper endoscopy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e47 (73)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026mdash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eContrast esophagram\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e61 (95)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u0026mdash;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eEsophageal manometry\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e18 (28)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e9 (14)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eTable 2. Diagnostic Gaps in Preoperative Evaluation\\u003c/p\\u003e\\n\\u003cp\\u003ePostoperative-only investigations were considered sequencing-related diagnostic gaps, as they did not inform preoperative surgical decision-making\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"3\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 498px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDiagnostic category\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 498px;\\\"\\u003e\\n \\u003cp\\u003eComplete minimum dataset (no gaps)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98px;\\\"\\u003e\\n \\u003cp\\u003e18 (28)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 498px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026ge;1 diagnostic gap\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98px;\\\"\\u003e\\n \\u003cp\\u003e46 (72)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 498px;\\\"\\u003e\\n \\u003cp\\u003eSingle diagnostic gap\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98px;\\\"\\u003e\\n \\u003cp\\u003e29 (45)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 498px;\\\"\\u003e\\n \\u003cp\\u003eMultiple diagnostic gaps (\\u0026ge;2 components missing)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98px;\\\"\\u003e\\n \\u003cp\\u003e17 (27)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 498px;\\\"\\u003e\\n \\u003cp\\u003eDysphagia with absent preoperative manometry\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98px;\\\"\\u003e\\n \\u003cp\\u003e11 / 17 (65)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 498px;\\\"\\u003e\\n \\u003cp\\u003eDiagnostic gaps were defined as absence of a minimum dataset component prior to surgery or completion of that component only after surgery\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 98px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bsur\",\"sideBox\":\"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bsur/default.aspx\",\"title\":\"BMC Surgery\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Antireflux surgery, gastroesophageal reflux disease, diagnostic gaps, preoperative \",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8588836/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8588836/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003cbr\\u003e\\nOptimal 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003cbr\\u003e\\nWe 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.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003cbr\\u003e\\nThe 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%).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e\\u003cbr\\u003e\\nIn 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.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Real-World Diagnostic Gaps in Patients Undergoing Antireflux Surgery: A Retrospective Process-of-Care Analysis\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-01 19:34:30\",\"doi\":\"10.21203/rs.3.rs-8588836/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"322228948847364068694320206241936425912\",\"date\":\"2026-04-04T17:57:10+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-03T19:30:23+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"203176926609555766802607539433759803770\",\"date\":\"2026-04-03T02:09:22+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"253513309245748612667471248061070716105\",\"date\":\"2026-03-30T16:50:22+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"113787496052394942730049127055406010899\",\"date\":\"2026-03-30T16:38:45+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-03-30T16:06:10+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-02-06T15:07:40+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-04T11:43:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-02-04T11:38:22+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Surgery\",\"date\":\"2026-01-13T07:30:59+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bsur\",\"sideBox\":\"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bsur/default.aspx\",\"title\":\"BMC Surgery\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"6f53c11b-d157-4295-9878-5ac627edd449\",\"owner\":[],\"postedDate\":\"April 1st, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-01T19:34:30+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-04-01 19:34:30\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8588836\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8588836\",\"identity\":\"rs-8588836\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}