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Abstract
PURPOSE OF REVIEW We aim to review the endoscopic evaluation of post-fundoplication anatomy and its role in assessment of fundoplication outcomes and in pre-operative planning for reoperation in failed procedures. RECENT FINDINGS There is no universally accepted system for evaluating post-fundoplication anatomy endoscopically. However, multiple reports described the usefulness of post-operative endoscopy as a quality control measure and in the evaluation of complex cases such as repeat procedures and paraesophageal hernias (PEH). Endoscopic evaluation of post-fundoplication anatomy has an important role in assessing the outcomes of operative repair and pre-operative planning for failed fundoplications. Attempts have been made to characterize the appearance of the newly formed gastroesophageal valve after successful repairs and to standardize endoscopic reporting and classification of anatomic descriptions of failed fundoplications. However, there is no consensus. More studies are needed to evaluate the applicability and reproducibility of proposed endoscopic evaluation systems in order for such tools to become widely accepted.
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Massey BT, Simuncak C, LeCapitaine-Dana NJ, Pudur S. Transient lower esophageal sphincter relaxations do not result from passive opening of the cardia by gastric distention. Gastroenterology 2006; 130:89-95. [PMID: 16401472 DOI: 10.1053/j.gastro.2005.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2001] [Accepted: 10/12/2005] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Transient lower esophageal sphincter relaxation is the main mechanism for gastroesophageal reflux. Although there is evidence that transient lower esophageal sphincter relaxations are neurally mediated, another school of thought is that transient lower esophageal sphincter relaxations result from gastric distention, which shortens the sphincter to the point where it opens and the pressure decreases. We assessed the relationship of transient lower esophageal sphincter relaxation to gastroesophageal junction opening in an unsedated human model. METHODS Seven healthy volunteers (6 men and 1 woman, aged 18-53 years) were studied while they were sitting. Manometry was performed by using a sleeve catheter passed through 1 nostril. A 5.3-mm endoscope was placed through the other nostril to obtain a retroflexed view of the cardia. The biopsy channel was connected to a barostat to distend the stomach with air at 15 mm Hg for 30 minutes. Manometric and endoscopic video-recording times were synchronized but scored independently. RESULTS The transient lower esophageal sphincter relaxation onset invariably preceded gastroesophageal junction opening (median, 5.0 seconds; range, 0.5-20.7 seconds; P < .001). The transient lower esophageal sphincter relaxation nadir also typically occurred before gastroesophageal junction opening (median, 2.1 seconds; range, -4.2 to +19.5 seconds; P < .001). Once open, the gastroesophageal junction moved proximally for the duration of the transient lower esophageal sphincter relaxation. Termination of transient lower esophageal sphincter relaxations occurred about the time the time of gastroesophageal junction closure. CONCLUSIONS These data refute the hypothesis that transient lower esophageal sphincter relaxations result from passive mechanical distraction of the gastroesophageal junction. Rather, transient lower esophageal sphincter relaxations must occur before the gastroesophageal junction can open.
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Affiliation(s)
- Benson T Massey
- Division of Gastroenterology & Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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3
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Abstract
BACKGROUND The problem of eliminating gastroesophageal reflux (GER) with simple, effective and devoid of unpleasant side effects procedures is still unresolved. We tried to settle this problem with a magnetic device that should be applied to the distal end of the esophagus. MATERIALS AND METHODS Two plastoferrite magnets of 2 x 4 x 0.5cm(1) were applied, on the opposite sides of a flaccid polyethylene tube mimicking the physical characteristics of the terminal esophagus. The two magnets attracting themselves compressed the tube, creating an artificial high-pressure zone that divided the tube in two segments. Both segments of the tube were connected to pressure transducers and a polygraph and one of them was connected to a hydraulic pump. The pressure was progressively increased in this segment up to a value sufficient to detach the magnets with consequent flowing of the water in the other segment of the tube. RESULTS The progressive increase of the pressure in a segment of the tube detached the magnets allowing a free flow into the other segment when the pressure reached an average value of 9.75+/-1.05 mmHg (mean+/-SD). CONCLUSIONS A couple of magnets clamping a tube with the characteristics of the distal esophagus is able to prevent the passage of liquid with a pressure value near to that of a normal lower esophageal sphincter. This magnetic device could be useful to maintain closed a sphincter unable to prevent gastroesophageal reflux.
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Affiliation(s)
- M Bortolotti
- Department of Internal Medicine, University of Bologna, Via Massarenti 48, 40138 Bologna, Italy.
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Chrysos E, Athanasakis E, Pechlivanides G, Tzortzinis A, Mantides A, Xynos E. The effect of total and anterior partial fundoplication on antireflux mechanisms of the gastroesophageal junction. Am J Surg 2004; 188:39-44. [PMID: 15219483 DOI: 10.1016/j.amjsurg.2003.10.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2003] [Revised: 10/31/2003] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication. METHODS Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension. RESULTS Both types of fundoplication resulted in significant increases in LES resting (P <0.001) and postdeglutition relaxation pressure (P <0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04). CONCLUSIONS Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.
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Affiliation(s)
- Emmanuel Chrysos
- Laboratory of Gastrointestinal Motility, University Hospital of Heraklion, GR-711 10 Heraklion, Crete, Greece.
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Jobe BA, Kahrilas PJ, Vernon AH, Sandone C, Gopal DV, Swanstrom LL, Aye RW, Hill LD, Hunter JG. Endoscopic appraisal of the gastroesophageal valve after antireflux surgery. Am J Gastroenterol 2004; 99:233-43. [PMID: 15046210 DOI: 10.1111/j.1572-0241.2004.04042.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Little consensus exists regarding the endoscopic assessment of the esophagogastric junction after antireflux surgery. The purpose of this report is to characterize the gastroesophageal valve appearance unique to each type of antireflux procedure and to introduce an endoscopic lexicon by which to describe this anatomic region. METHODS Endoscopic images were obtained from patients who had undergone any one of the following procedures: Nissen, Collis-Nissen, Toupet, and Dor fundoplications and Hill repair. Images were excluded if patients had any symptoms of heartburn, regurgitation, dysphagia, chest pain, or gas bloat or if they were using antisecretory medication. Seven photographs per operation type were evaluated by experienced surgeons and gastroenterologists tasked with describing defining characteristics of each procedure. RESULTS Ten valve criteria were developed to uniquely identify and quantify the ideal endoscopic appearance of each procedure. Illustrations were created to clearly depict those traits. CONCLUSIONS Using 10 gastroesophageal valve criteria, the key components of a successful functional repair of the esophagogastric junction were defined. These criteria can be employed when evaluating upper gastrointestinal complaints after antireflux surgery and may ultimately serve as a dependable outcome measure.
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Affiliation(s)
- Blair A Jobe
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Donkervoort SC, Bais JE, Rijnhart-de Jong H, Gooszen HG. Impact of anatomical wrap position on the outcome of Nissen fundoplication. Br J Surg 2003; 90:854-9. [PMID: 12854113 DOI: 10.1002/bjs.4123] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The importance of anatomical reposition and fixation of the type I hiatal hernia during antireflux surgery has often been emphasized. It is not known whether the initial anatomical repair withstands the test of time and whether this repair is necessary for a successful outcome. METHODS The relationship between the objective anatomical and subjective symptomatic outcome of Nissen fundoplication was investigated prospectively in 57 patients. Findings of herniation, telescoping and obstruction at the level of the lower oesophageal sphincter on barium swallow were scored 2 years after operation by investigators who were unaware of the symptoms, and were related to symptoms and patient satisfaction evaluated by a standard questionnaire. RESULTS According to strict criteria, some 55 per cent of patients had some degree of anatomical failure; if only complete herniation, significant telescoping and signs of obstruction were scored as abnormal, 27 per cent had anatomical failure. There was no relation to subjective outcome; relief was reported by 48 of 49 patients, 25 of whom were cured and 23 significantly improved. CONCLUSION Anatomical repair during antireflux surgery does not stand the test of time. Although this has no demonstrable influence on the subjective outcome, the authors do not recommend deviating from well designed surgical guidelines. Current theories on the mechanism of antireflux surgery require further evaluation.
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Affiliation(s)
- S C Donkervoort
- Department of Surgery, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Jobe BA, Rosenthal E, Wiesberg TT, Cohen JI, Domreis JS, Deveney CW, Sheppard B. Surgical management of gastroesophageal reflux and outcome after laryngectomy in patients using tracheoesophageal speech. Am J Surg 2002; 183:539-43. [PMID: 12034388 DOI: 10.1016/s0002-9610(02)00828-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is common in patients with head and neck carcinoma. The impact of laparoscopic fundoplication on laryngectomy patients with tracheoesophageal prostheses for voice restoration is unknown. METHODS Nine laryngectomy patients who use tracheoesophageal speech underwent laparoscopic fundoplication for documented reflux. Preoperative and postoperative symptoms were recorded. Quality of speech was documented before and after fundoplication. RESULTS Although 88% of patients had resolution of GERD symptoms, all developed bloating and hyperflatulence. There was no difference in quality of esophageal speech after laparoscopic fundoplication. CONCLUSIONS Fundoplication in laryngectomy patients that use tracheoesophageal speech eliminates symptoms of gastroesophageal reflux and resolves regurgitation associated prosthesis erosion. Although nearly all patients are satisfied with outcome, there is a high incidence of postfundoplication bloating and hyperflatulence that may be life limiting. Poor quality tracheoesophageal speech should not be used as an indication for antireflux surgery.
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Affiliation(s)
- Blair A Jobe
- Department of Surgery, Oregon Health Sciences University, Portland, OR, USA.
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Abstract
The use of cadavers in experimental esophageal surgery is reviewed. Items useful to cadaveric studies such as post-mortem changes, biosafety, ethics, and legislation are discussed. Tactics used in minimally invasive procedures (thoracoscopy and laparoscopy) are shown. Cadaveric use in studies concerning esophagectomy, gastroesophageal reflux disease, esophageal atresia, Boerhaave's syndrome, and Mallory-Weiss tears are discussed. It is concluded that human bodies represent a good but underused model for esophageal surgery.
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Affiliation(s)
- F A Herbella
- Surgical Gastroenterology Department, Federal University of São Paulo, São Paulo, Brazil.
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Abstract
BACKGROUND Dysphagia is experienced by many patients after antireflux surgery. This literature review examines factors associated with the development, prediction and management of postoperative dysphagia. METHODS Published studies examining issues related to dysphagia, gastro-oesophageal reflux and fundoplication were reviewed. RESULTS Postoperative dysphagia is usually temporary but proves troublesome for 5--10 per cent of patients. Technical modifications, such as a partial wrap, division of short gastric vessels and method of hiatal closure, have not conclusively reduced its incidence. There is no reliable preoperative test to predict dysphagia. CONCLUSION It is uncertain whether postoperative dysphagia arises from patient predilection or is largely a consequence of mechanical changes created by fundoplication. Anatomical errors account for a significant proportion of patients referred for correction of dysphagia but these are uncommon in large single-institution studies. Abnormal manometry cannot predict dysphagia and, on current evidence, 'tailoring' the operation does not prevent its occurrence.
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Affiliation(s)
- V L Wills
- St George Upper Gastrointestinal Surgical Unit, 1 South Street, Kogarah, 2217 New South Wales, Australia
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Heider TR, Farrell TM, Kircher AP, Colliver CC, Koruda MJ, Behrns KE. Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility. J Gastrointest Surg 2001; 5:36-41. [PMID: 11309646 DOI: 10.1016/s1091-255x(01)80011-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fundoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 +/- 1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (#30 mm Hg mean distal esophageal body pressure or #80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted.
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Affiliation(s)
- T R Heider
- Section of Gastrointestinal Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7210, USA
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Reardon PR, Matthews BD, Scarborough TK, Preciado A, Marti JL, Kamelgard JI. Geometry and reproducibility in 360 degrees fundoplication. Surg Endosc 2000; 14:750-4. [PMID: 10954823 DOI: 10.1007/s004640000172] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND In this study, we set out to precisely define two symmetrical points-a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or "floppy") 360 degrees fundoplication (FP). METHODS For the terms of this study, circumference = c; diameter = d; c/d = pi; pi = 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n = 5) and intraoperatively (n = 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c. RESULTS The smallest measured value for c was 7.5 cm (d = 2.39 cm); the largest value for c was 10.0 cm (d = 3.18 cm). The mean value was 8.35 cm (d = 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d = 2.66 cm. This technique creates a correctly oriented, symmetrical, "floppy," true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible. CONCLUSIONS Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a "floppy" 360 degrees fundoplication.
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Affiliation(s)
- P R Reardon
- Department of Surgery, Baylor College of Medicine, 6550 Fannin, Houston, TX 77030, USA
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Farrell TM, Archer SB, Galloway KD, Branum GD, Smith CD, Hunter JG. Heartburn is More Likely to Recur after Toupet Fundoplication than Nissen Fundoplication. Am Surg 2000. [DOI: 10.1177/000313480006600302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Toupet (270°) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360°) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 (“none”) to 3 (“severe”) scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.
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