DOI: 10.1148/rg.256055016
Surgical Approach to Gastroesophageal Reflux Disease: What the Radiologist Needs to Know1
Cheri L. Canon, MD,
Desiree E. Morgan, MD,
David M. Einstein, MD,
Brian R. Herts, MD,
Mary T. Hawn, MD and
Lawrence F. Johnson, MD
1 From the Department of Radiology (C.L.C., D.E.M.) and the Departments of Surgery (M.T.H.) and Medicine (L.F.J.), Division of Gastroenterology, University of Alabama at Birmingham, 619 S 19th St, Birmingham, AL 35249-6830; and the Division of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio (D.M.E., B.R.H.). Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received January 31, 2005; revision requested March 2 and received March 23; accepted March 24. All authors have no financial relationships to disclose.
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Figure 1. Schematic illustrates the selective preoperative testing algorithm used at our institution.
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Figure 2. Reflux esophagitis. Double-contrast radiograph of the distal esophagus reveals linear erosions near the gastroesophageal junction (GEJ) (arrows). Note the radiating folds extending to the erosions.
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Figure 3. Reflux stricture. Double-contrast radiograph reveals a focal stricture in the distal esophagus (straight arrow). Note the sacculation proximal to the stricture (curved arrow). This type of outpouching develops secondary to esophageal wall ballooning between areas of fibrosis.
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Figure 4. Barrett esophagus. Double-contrast radiograph shows a circumferential stricture in the midesophagus (arrow) with reticular mucosa, findings that are not often seen in Barrett esophagus.
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Figure 5. Esophageal adenocarcinoma. Double-contrast radiograph obtained in a different patient with Barrett esophagus shows a stricture in the midesophagus (large straight arrow). The irregularity of the stricture, combined with its abrupt border (small straight arrows), suggests that it is malignant. Note also the distal peptic stricture at the GEJ (curved arrow) and the sliding hiatal hernia (*).
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Figure 6. Spot radiograph shows a normal GEJ (straight arrow), which is identified where the gastric folds terminate. The diaphragmatic hiatus (curved arrow) is located at the "pinch" where the esophageal lumen narrows as it crosses the crura. It is important to remember that the GEJ moves with change of patient position and during normal inspiration.
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Figure 7. Spot radiograph of the GEJ reveals the pinch (curved arrow) where the lumen crosses the esophageal hiatus. Note that, in this case, the hiatus does not correlate with the diaphragmatic shadow (straight arrow).
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Figure 8. Radiograph shows a normal esophageal vestibule, the radiographic component of the lower esophageal sphincter. The vestibule is bordered superiorly by a muscular A ring (arrow) and inferiorly by the B ring, which occurs at the GEJ or z line in healthy patients. The phrenicoesophageal ligament attaches the vestibule to the adjacent diaphragmatic crus, anchoring the esophagus as it crosses the hiatus. A large esophageal vestibule can mimic a type I hiatal hernia.
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Figure 9. Type I (sliding) hiatal hernia. Radiograph shows the GEJ (black arrow) displaced superiorly above the esophageal hiatus, which is indicated by the pinched appearance as the gastric folds traverse the hiatus (white arrow). It is important to note the reducibility of the hernia. If it is not reducible, the esophagus is likely shortened, posing an important complication for the surgeon because it will affect which surgical procedure is performed.
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Figure 10a. Reducible type I hiatal hernia. (a) Spot radiograph of the proximal stomach obtained with the patient supine shows the gastric fundus (*) lying above the diaphragm. (b) On an upright radiograph, the hernia is completely reduced below the diaphragm. The GEJ (arrow) is identifiable by noting the termination point of the converging gastric folds.
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Figure 10b. Reducible type I hiatal hernia. (a) Spot radiograph of the proximal stomach obtained with the patient supine shows the gastric fundus (*) lying above the diaphragm. (b) On an upright radiograph, the hernia is completely reduced below the diaphragm. The GEJ (arrow) is identifiable by noting the termination point of the converging gastric folds.
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Figure 11a. Type II hiatal hernia (paraesophageal hernia). (a) Spot radiograph of the distal esophagus and proximal stomach reveals the entire gastric fundus (*) lying above the diaphragm. Note the pinch where the gastric folds traverse the hiatus (arrow). These findings initially seem to indicate a type I hernia. (b) Oblique radiograph shows the GEJ (arrow) coursing posterior to the herniated fundus. The GEJ actually lies at the level of the diaphragm, making this a type II hernia.
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Figure 11b. Type II hiatal hernia (paraesophageal hernia). (a) Spot radiograph of the distal esophagus and proximal stomach reveals the entire gastric fundus (*) lying above the diaphragm. Note the pinch where the gastric folds traverse the hiatus (arrow). These findings initially seem to indicate a type I hernia. (b) Oblique radiograph shows the GEJ (arrow) coursing posterior to the herniated fundus. The GEJ actually lies at the level of the diaphragm, making this a type II hernia.
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Figure 12a. Type III hiatal hernia. (a) Upright radiograph of the GEJ reveals a large hernia (*). (b) Oblique radiograph reveals a partially reduced paraesophageal component of the hernia (white arrow). In addition, the GEJ (black arrow) lies well above the level of the diaphragmatic hiatus.
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Figure 12b. Type III hiatal hernia. (a) Upright radiograph of the GEJ reveals a large hernia (*). (b) Oblique radiograph reveals a partially reduced paraesophageal component of the hernia (white arrow). In addition, the GEJ (black arrow) lies well above the level of the diaphragmatic hiatus.
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Figure 13. Type IV hernia (intrathoracic stomach). Spot radiograph reveals a large hernia, with the majority of the stomach lying in the chest and displacing the distal esophagus (straight arrow). The intrathoracic stomach usually rotates 180° along its longitudinal axis, resulting in the displacement of the greater curvature (curved arrow) superior to the lesser curvature.
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Figure 14. Shortened esophagus. Spot radiograph reveals a nonreducible type I hernia. The GEJ (arrow) is situated well above the diaphragmatic hiatus (arrowhead), and the hernia did not reduce.
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Figure 15a. Nissen fundoplication. (a) Drawing illustrates the fundus wrapped posteriorly around the distal esophagus and lower esophageal sphincter. (b) Drawing illustrates the fundus sutured anteriorly, making a complete 360° wrap. Note that the wrap extends for approximately 2–3 cm, encircles the lower esophageal sphincter, and lies below the level of the diaphragm. At least one of the sutures involves the esophageal wall to prevent slippage. If the esophageal hiatus is enlarged, the crura are approximated. (Reprinted, with permission, from reference 25.)
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Figure 15b. Nissen fundoplication. (a) Drawing illustrates the fundus wrapped posteriorly around the distal esophagus and lower esophageal sphincter. (b) Drawing illustrates the fundus sutured anteriorly, making a complete 360° wrap. Note that the wrap extends for approximately 2–3 cm, encircles the lower esophageal sphincter, and lies below the level of the diaphragm. At least one of the sutures involves the esophageal wall to prevent slippage. If the esophageal hiatus is enlarged, the crura are approximated. (Reprinted, with permission, from reference 25.)
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Figure 16. Toupet fundoplication. Drawing illustrates that, like Nissen fundoplication, Toupet fundoplication involves wrapping the fundus posterior to the esophagus; however, the result is not a complete 360° wrap but an approximately 270° wrap, anchored to the crus (arrow) and the esophagus. (Reprinted, with permission, from reference 26.)
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Figure 17a. Collis gastroplasty. (a) Drawing illustrates how a neoesophagus is created by stapling the gastric cardia in line with the esophagus. (b) Drawing illustrates a wrap around the neoesophagus and below the diaphragm. (Reprinted, with permission, from reference 33.)
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Figure 17b. Collis gastroplasty. (a) Drawing illustrates how a neoesophagus is created by stapling the gastric cardia in line with the esophagus. (b) Drawing illustrates a wrap around the neoesophagus and below the diaphragm. (Reprinted, with permission, from reference 33.)
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Figure 18. Nissen fundoplication. Spot radiograph of the distal esophagus and stomach reveals a typical fundoplication defect (black arrows). Note the circumferential narrowing of the distal esophagus and GEJ (white arrow), extending for approximately 2–3 cm. The wrap is subdiaphragmatic.
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Figure 19. Nissen fundoplication. Radiograph shows a filling defect in the fundus (straight arrows) from the wrapped portion of the fundoplication. In addition, there is smooth, tapered narrowing of the distal esophagus and GEJ (curved arrow).
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Figure 20. Toupet fundoplication. Radiograph demonstrates a partial posterior wrap filled with barium (arrow), a finding that does not necessarily indicate wrap dehiscence. It is not always possible to differentiate between a Toupet fundoplication and a Nissen fundoplication at radiography.
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Figure 21. Collis gastroplasty with Nissen fundoplication. Radiograph shows a wrap extending around the neoesophagus created by the gastric cardia. This is evidenced by the wrap encircling the gastric folds (black arrow). Note that the wrap and the GEJ (white arrow) lie below and above the hemidiaphragm, respectively.
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Figure 22. Collis gastroplasty with Nissen fundoplication. Radiograph shows the wrap (arrow) encircling the gastric folds and lying below the GEJ.
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Figure 23. Tight Nissen fundoplication resulting in postoperative dysphagia. Spot radiograph of the GEJ reveals marked narrowing from the wrap (arrow). There was retained barium in the esophagus with the patient in the upright position, and a 12.5-mm tablet would not pass beyond the wrap. This finding is most commonly seen in the immediate postoperative period, is secondary to edema, and should resolve within 2 weeks.
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Figure 24. Perforation after Nissen fundoplication. Contrast-enhanced computed tomographic (CT) scan through the lower chest reveals an air-fluid collection (*) posterior to the distal esophagus (arrow). Perforation secondary to fundoplication is uncommon, since the mucosal barrier is typically not breached.
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Figure 25. Dysphagia. Tight Nissen fundoplication in a patient who presented with dysphagia beyond the immediate postoperative period. Spot radiograph reveals a severely narrowed distal esophagus and GEJ (arrow). The barium tablet was obstructed by this too-tight wrap.
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Figure 26. Dysphagia. On a radiograph obtained in a different patient who presented with dysphagia after undergoing fundoplication, the wrap does not appear too tight, but it is well beyond the normal 2–3 cm in length.
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Figure 27. Gas bloat syndrome after Nissen fundoplication. The patient presented with typical symptoms, including upper abdominal fullness and inability to belch. Radiograph of the esophagus reveals a somewhat narrowed distal esophagus and GEJ (black arrow) secondary to Nissen fundoplication. Note the soft-tissue filling defect of the wrap (white arrow) as outlined by gas in the gastric fundus. The wrap is appropriately situated below the diaphragm.
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Figure 28. Complete fundoplication dehiscence. Steep right lateral oblique radiograph, obtained in a patient with a remote history of Nissen fundoplication who presented with symptoms of reflux, reveals a normal-appearing stomach and distal esophagus. Note that there is no typical tapering of the GEJ or filling defect in the fundus to suggest fundoplication. A completely dehisced fundoplication often mimics normal findings in a healthy patient who has not undergone surgical intervention. In addition, patients with complete fundoplication dehiscence usually have marked reflux.
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Figure 29. Complete fundoplication dehiscence. Radiograph obtained in a patient who had undergone Toupet fundoplication shows no narrowing of the distal esophagus or GEJ but does reveal herniation of a small portion of the gastric fundus in a paraesophageal location (arrows).
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Figure 30. Partial Nissen fundoplication dehiscence. Lateral spot radiograph of the stomach and esophagus reveals a distorted fundus. Although the wrap has a posterior component (*), it does not completely encircle the GEJ. Note also that there is no significant tapering of the distal esophagus or GEJ. The patient experienced continual spontaneous reflux during the examination. Even if a fundoplication has a normal radiographic appearance, the presence of reflux during the examination proves that the fundoplication has failed.
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Figure 31. Recurrent hernia (intrathoracic migration of the wrap). Spot radiograph reveals narrowing through the fundoplication, which remains intact (*). Note, however, that the entire wrap lies above the esophageal hiatus (arrow), as evidenced by the pinched appearance where the gastric folds traverse the hiatus.
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Figure 32. Recurrent hernia in a patient with postprandial chest fullness but no symptoms of reflux. Upper abdominal spot radiograph reveals a large portion of the proximal stomach herniated above the diaphragm. Reflux was not elicited during the study. At laparoscopy, the wrap was intact but the crus was gaping.
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Figure 33. Slipped fundoplication accompanied by recurrent reflux symptoms. Spot radiograph reveals an intact wrap encircling the proximal stomach (straight arrows). The GEJ (curved arrow) has multiple ring-like strictures and lies above the diaphragm.
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Figure 34. Slipped fundoplication accompanied by recurrent reflux symptoms. Lateral radiograph obtained in a different patient shows a fundoplication (straight arrow) encircling the proximal stomach, as evidenced by the gastric folds. The GEJ (curved arrow) lies above the level of the wrap.
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Figure 35. Slipped fundoplication. Radiograph shows a wrap encircling the proximal stomach (arrow) well below the GEJ.
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Copyright © 2005 by the Radiological Society of North America.
