DOI: 10.1148/rg.256055016
RadioGraphics 2005;25:1485-1499
© RSNA, 2005
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.
Address correspondence to C.L.C. (e-mail: ccanon{at}uabmc.edu).
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Abstract
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Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.
© RSNA, 2005
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LEARNING OBJECTIVES FOR TEST 1
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After reading this article and taking the test, the reader will be able to:
- List the various types of fundoplication.
- Discuss the pre-and postoperative evaluation of patients who undergo fundoplication.
- Describe the radiographic appearances of complications of fundoplication.
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Introduction
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Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms, injury to the esophageal epithelium, or both (1). It is the most common inflammatory disease of the esophagus. GERD results in epithelial damage by means of two general mechanisms: Either defective antireflux and luminal clearance mechanisms overwhelm a previously healthy epithelium, or primary defects within the epithelium allow "normal" acid contact times to produce inflammation (2). Most investigators consider GERD to be a spectrum ranging from mild non-erosive forms in patients with heartburn to metaplasia and adenocarcinoma. However, other investigators propose adopting a new framework in which GERD patients are considered to have one of three distinct conditions: nonerosive reflux disease, erosive esophagitis, or Barrett esophagus (3–6). Regardless of this controversy over categorization, GERD accounted for $13 billion in health care expenditures in the United States last year alone. Although medical management has improved greatly in recent years, an increasing number of laparoscopic fundoplications are being performed for this problem. The benefits of medical versus surgical therapy for GERD are under ongoing investigation (7–10).
In this article, we discuss and illustrate the medical management of GERD as well as its surgical management, including preoperative evaluation, specific surgical procedures, the normal radiographic appearance of fundoplication, and the various postoperative complications and their radiographic appearances.
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Medical Management
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Medical management strategies include self-medication with over-the-counter antacids, H2 receptor antagonists, and proton pump inhibitors (PPIs). PPIs afford the highest levels of symptomatic relief and esophageal healing (5,11–14). Approximately 75%–80% of patients with mild esophagitis and 50% with severe esophagitis are healed with PPIs, and maintenance PPIs are effective in preventing recurrence of peptic esophageal strictures (8). Even in patients with nonerosive GERD, PPIs provide symptomatic relief in 50%–65% of cases (11). However, 80% of patients may have recurrent symptoms after discontinuing PPI therapy (12). Most initial treatment of GERD patients occurs in the primary care setting, with the focus in gastroenterology shifting to treating patients who do not respond to initial therapy (5,11).
Patients in whom medical treatment has failed include those with symptoms after 8–12 weeks of aggressive acid suppression, those who are "medically dependent," and those with unacceptable side effects from medication. Other patients may desire surgery to avoid expensive long-term PPI therapy (5,13). Options for patients in whom "good" medical management has failed include laparoscopic or open fundoplication, both of which surgical techniques are widely available, and a variety of newer endoscopic interventions that are promising but currently not as accessible (15–17).
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Surgical Management
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Patients with GERD who are refractory to or have inadequate control with PPI therapy are considered for fundoplication. Other selection criteria are (a) reflux with a symptomatic hiatal hernia and (b) extraesophageal symptoms of reflux including asthma, cough, and throat clearing. Preoperative evaluation may include pH monitoring, esophageal manometry, upper endoscopy, and barium swallow examination. The use of these studies varies widely among practitioners, as does their availability among institutions (6,18,19). The relative strengths and weaknesses of available preoperative tests are summarized in the Table.
At our institution, we use a selective preoperative testing approach (Fig 1) similar to that described by Frantzides et al (18). It is important that all patients being considered for surgical GERD therapy undergo a barium swallow examination.
Preoperative barium swallow examination must allow critical evaluation of (a) esophageal peristalsis; (b) complications including esophagitis (Fig 2), stricture (Fig 3), Barrett esophagus (Fig 4), and adenocarcinoma (Fig 5); (c) the presence and type of hiatal hernia; (d) the presence of a shortened esophagus manifesting as a hiatal hernia that does not reduce with the patient in the upright position; and (e) the presence and extent of gastroesophageal reflux.
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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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Motility disorders are well depicted at barium swallow examination. It is crucial that this portion of the examination be performed with the patient recumbent, thereby removing the influences of gravity. The presence and type of disorder represent vital information for the surgeon, since patients with GERD may have symptoms that overlap with those of patients with achalasia, scleroderma, or diffuse esophageal spasm. Up to 50% of GERD patients have dysmotility in which there is slowing or weakening of primary esophageal peristalsis, referred to as "nonspecific motility disorder" or "ineffective swallow." This condition will generally improve after surgery (20,21). However, performing fundoplication in a patient with undiagnosed achalasia, diffuse esophageal spasm, or scleroderma can lead to an unfavorable surgical outcome.
Esophagitis is defined as defects in esophageal mucosa that result when epithelial cells succumb to the caustic effects of reflux acid and pepsin. Radiographic findings include granularity-edema of mucosa, thickened folds–edema of submucosa, ulcerations, punctate shallow ulcers at or near the GEJ, and longitudinally oriented linear ulcers or erosions (Fig 2), findings that typically extend through the lower one-third to one-half of the esophagus.
Diagnosis of a hiatal hernia is sometimes misunderstood. To correctly identify a hernia, one must first correctly identify the GEJ, which is typically located at the termination point of the converging gastric folds. Next, the diaphragmatic hiatus must be identified, as evidenced by the "pinched" appearance where the gastric folds traverse the hiatus. A distance of more than 1.5 cm between these two anatomic landmarks indicates a sliding hiatal hernia. It is important for the radiologist to remember that (a) the location of the GEJ is dynamic (Fig 6), (b) the hiatus does not always correlate with the diaphragmatic shadow (Fig 7), and (c) a normal esophageal vestibule can mimic a sliding hiatal hernia (Fig 8). Having the patient perform the Valsalva maneuver while prone may be the only way to diagnose a small, reducible 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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The size and type of hiatal hernia (Figs 9–13) are also of interest to the surgeon. There are four types of hiatal hernias, the most common of which is type I (sliding) hernia. In a type II (paraesophageal) hernia, the GEJ remains at or below the level of the diaphragm and the gastric fundus herniates superiorly in a paraesophageal location. Type III hernia is more common than type II and has features of both type I (sliding) and type II (paraesophageal) hernias. In type IV hernias, all or part of the stomach herniates into the thorax, usually with organoaxial rotation of the stomach. Large hernias may be associated with a shortened esophagus and have been linked to surgical failure (22). Similarly, a shortened esophagus is suggested if a hernia does not reduce when the patient is upright.
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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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Strictures are caused by collagen deposition stimulated by healing ulcers or esophagitis. Longitudinal stricture results in a shortened esophagus (Fig 14), which it is critical to diagnose preoperatively. The lower esophageal sphincter must be wrapped below the diaphragm for an effective outcome. If there is longitudinal fibrosis, generally due to chronic and moderately severe reflux (23), it may not be possible to secure the distal esophagus below the diaphragm, and an esophageal lengthening procedure (Collis gastroplasty) may be required. If the lengthening procedure is not performed, a recurrent hiatal hernia and failed fundoplication will likely result.
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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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Radiographic findings in stricture include circumferential peptic strictures, Schatzki ring, other distal strictures, sacculations (Fig 3), and fixed transverse folds.
Barrett esophagus arises when healing of esophageal inflammation occurs in a persistent acid environment. This is a metaplastic process in which squamous epithelium is replaced with columnar epithelium. Radiographic findings in Barrett esophagus include a high or midesophageal stricture or ulcer that is clearly situated above the GEJ and a fine reticulonodular mucosal pattern (Fig 4), although many affected patients do not have the latter finding.
Esophageal adenocarcinoma has an increasing prevalence and has now surpassed squamous carcinoma as the most common esophageal malignancy. Esophageal adenocarcinoma has a prevalence of 1%–2% in the adult population of the United States that increases to 10%–15% in patients undergoing endoscopy for GERD evaluation. The risk for cancer in patients with Barrett esophagus is approximately 30–60 times that in the general population (24).
Barium swallow examination can help detect and determine the extent of reflux, even though it is not the most sensitive test in this setting. In addition to identifying spontaneous reflux, the radiologist should attempt to provoke reflux by having the patient assume different positions, cough, or perform the Valsalva maneuver or by conducting a water-siphon test. The level of refluxate in the esophagus and the time required for clearance should be noted so that the surgeon has an idea of the extent of reflux and the length of time the reflux is in contact with the esophagus.
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Surgical Procedures
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Once the decision to perform surgical intervention has been made, there are a number of options for fundoplication, most commonly Nissen fundoplication (360° wrap) (Fig 15) and Toupet fundoplication (270° posterior wrap) (Fig 16). Dor fundoplication is a 180° anterior wrap and is less common. The type of fundoplication performed is often linked to the surgeon’s experience and preferences, as well as to the results of preoperative motility evaluation. Today, fundoplications are most commonly performed laparoscopically (27) but may be performed with a conventional open surgical technique if necessary. In general, laparoscopic techniques result in shorter hospital stays and recovery times than do open surgical procedures, with similar success rates (28,29). There is some controversy concerning partial versus complete wraps. Partial wraps do not lead to a lesser degree of dysphagia than do 360° wraps and in some studies have been associated with increased postoperative heartburn symptoms (21). Gas bloat syndrome may occur more frequently in patients with 360° wraps, since published data indicate higher intragastric pressure with distention in patients who undergo Nissen fundoplication as opposed to anterior partial fundoplication (30). Other published data indicate no significant differences in symptoms at midterm follow-up between patients who undergo full wraps and those who undergo partial wraps (28,29,31), noting that over time many surgical patients develop some recurrence of heartburn (10,15,32). In patients with a shortened esophagus, Collis gastroplasty (Fig 17) may also be performed laparoscopically. In all patients, whether a thoracic or an abdominal approach is used, the wrap and the lower esophageal sphincter must be below the diaphragm.
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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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Radiologists should be familiar with normal postfundoplication findings on contrast material–enhanced studies (Figs 18–22). There should be a tapered narrowing of the distal esophagus and the GEJ that extends for 2–3 cm. This wrapped segment should be below the diaphragmatic hiatus.
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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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Postoperative Complications
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Immediate postoperative complications that might require radiologic evaluation include dysphagia (Fig 23) (34) and perforation (Fig 24). Because of the risk of leakage in the immediate postoperative period, water-soluble contrast material is used. If no leak is detected, barium is administered. Typically, a full-column examination is performed with the patient in the upright position followed by multiple supine-oblique positions. The radiographic technique for remote postoperative evaluation of the esophagus is identical to that for preoperative evaluation, with the addition of air-contrast views of the fundoplication obtained after rolling the recumbent patient several times in an attempt to coat the fundoplication with barium. However, to exclude obstruction, a single swallow of barium should be administered before the administration of the bicarbonate crystals.
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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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Longer-term postoperative symptoms that often require radiographic evaluation include dysphagia (Figs 25, 26), gas bloat syndrome (Fig 27), and recurrent heartburn. Complications including complete fundoplication dehiscence (Figs 28, 29), partial dehiscence (Fig 30), recurrent hernia (Figs 31, 32) (35), and slipped wrap (Figs 33–35) are generally evaluated with barium swallow examination; however, given the increasing numbers of CT studies performed for other indications, these complications may be evident with cross-sectional techniques as well. A recurrent hernia should not be confused with a slipped fundoplication, which occurs when the fundoplication slips distally and encircles the stomach rather than the GEJ. However, both complications often occur in the setting of a fundoplication that was performed on a shortened esophagus without incorporating an esophageal lengthening procedure. In this setting, the shortened esophagus pulls the intact wrap above the diaphragm, or, if the esophageal hiatus has been adequately repaired, the wrap may simply slip more distally as the esophagus is retracted into the chest. It is extremely important for the radiologist to identify a shortened esophagus preoperatively, so that the appropriate Collis gastroplasty can be performed.
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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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Several published studies have shown that symptoms are an unreliable indicator of the presence of recurrent reflux (36) and that many "anatomic" failures may be seen in postoperatively asymptomatic individuals (37); thus, evaluation of these patients ideally involves a team approach involving radiologists, surgeons, and gastroenterologists.
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Conclusions
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Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre-and postsurgical evaluation of these patients. Complications of GERD must be identified before performing surgical intervention. Most important, identification of a shortened esophagus is necessary so that the surgeon can incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, the wrap is likely to fail.
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Footnotes
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Abbreviations: GEJ = gastroesophageal junction, GERD = gastroesophageal reflux disease, PPI = proton pump inhibitor
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References
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Abstract
LEARNING OBJECTIVES FOR TEST...
