Original Communications| Volume 127, ISSUE 2, P200-208, February 2000

Esophagogastric junction pressure topography after fundoplication


      Objectives: This study compared the pressure topography after laparoscopic Nissen fundoplication to that of normal subjects and patients with hiatal hernia and reflux disease. Methods: Seven patients with fundoplication, 7 normal subjects and 7 patients with hiatal hernia, were studied. The squamocolumnar junction and intragastric margin of the esophagogastric junction (EGJ) were marked with metal clips. Axial and radial characteristics of EGJ pressure were mapped relative to the hernia and clipped during concurrent fluoroscopy and manometry. Responses to inspiration and abdominal compression were also analyzed. Results: Fundoplication modifies the EGJ by restoration of the hiatal component of EGJ pressure and elongation of the subdiaphragmatic component. Maximal EGJ pressure after fundoplication is mainly dependent on the extrinsic effect of the hiatal canal that compresses the esophagus; the resultant length of the EGJ reflects the length of the fundic wrap. Integrity of the EGJ after fundoplication is independent of the intrinsic lower esophageal sphincter itself. Conclusions: Fundoplication alters the pressure topography of the EGJ by reducing the hiatal hernia, tightening the hiatal orifice, and constructing a subdiaphragmatic wrap of variable length. Each effect depends on different technical aspects of the surgery with the potential of substantial variability in the resultant pressure topography. (Surgery 2000;127:200-8.)
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        • Hunter JG
        • Trus TL
        • Branum GD
        • Waring JP
        • Wood WC.
        A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.
        Ann Surg. 1996; 223: 673-677
        • Frantzides CT
        • Richards C.
        A study of 362 consecutive laparoscopic Nissen fundoplications.
        Surgery. 1998; 124: 651-655
        • Perdikis G
        • Hinder RA
        • Lund RJ
        • Raiser F
        • Katada N.
        Laparoscopic Nissen fundoplication: Where do we stand?.
        Surg Laparosc Endosc. 1997; 7: 17-21
        • Hill LD
        • Kozarek RA
        • Kraemer SJ
        • Aye RW
        • Mercer CD
        • Low DE
        • et al.
        The gastroesophageal flap valve: in vitro and in vivo observations.
        Gastrointest Endosc. 1996; 44: 541-547
        • Logemann JA
        • Kahrilas PJ
        • Begelman J
        • Dodds WJ
        • Pauloski BR.
        Interactive computer program for biomechanical analysis of videoradiographic studies of swallowing.
        Am J Roentgenol. 1989; 153: 277-280
        • Schulze K
        • Dodds WJ
        • Christensen J
        • Wood JD.
        Esophageal manometry in the opossum.
        Am J Physiol. 1977; 233: E152-E159
        • Klein WA
        • Parkman HP
        • Dempsey DT
        • Fisher RS.
        Sphincterlike thoracoabdominal high pressure zone after esophagogastrectomy.
        Gastroenterology. 1993; 105: 1362-1369
        • Kahrilas PJ
        • Lin S
        • Chen J
        • Manka M.
        The effect of hiatus hernia on gastro-oesophageal junction pressure.
        Gut. 1999; 44: 483-489
        • Mathew G
        • Watson DI
        • Myers JC
        • Holloway RH
        • Jamieson GG.
        Oesophageal motility before and after laparoscopic Nissen fundoplication.
        Br J Surg. 1997; 84: 1465-1469
        • DeMeester TR
        • Bonavina L
        • Albertucci M.
        Nissen fundoplication for gastroesophageal reflux disease: evaluation of primary repair in 100 consecutive patients.
        Ann Surg. 1986; 204: 9-20
        • Peters JH
        • DeMeester TR
        • Crookes P
        • Oberg S
        • de Vos Shoop M
        • Hagen JA
        • et al.
        The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with “typical” symptoms.
        Ann Surg. 1998; 228: 40-50
        • Liebermann-Meffert D
        • Allgöwer M
        • Schmid P
        • Blum AL
        Muscular equivalent of the lower esophageal sphincter.
        Gastroenterology. 1979; 76: 31-39
        • Hinder RA
        • Filipi CJ
        • Wetscher G
        • Neary P
        • DeMeester TR
        • Perdikis G.
        Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease.
        Ann Surg. 1994; 220: 472-483
        • Hunter JG
        • Swanstrom L
        • Waring JP.
        Dysphagia after laparoscopic antireflux surgery: impact of operative technique.
        Ann Surg. 1996; 224: 51-57
        • Donohue PE
        • Samelson S
        • Nyhus LM
        • Bombeck CT.
        The floppy Nissen fundoplication.
        Arch Surg. 1985; 120: 663-668
        • Stein HJ
        • DeMeester TR
        • Naspetti R
        • Jamieson J
        • Perry RE.
        Three-dimensional imaging of the lower esophageal sphincter in gastroesophageal reflux disease.
        Ann Surg. 1991; 214: 374-384
        • Kahrilas PJ
        • Dodds WJ
        • Dent J
        • Wyman JB
        • Hogan WJ
        • Arndorfer RC.
        Upper esophageal sphincter function during belching.
        Gastroenterology. 1986; 91: 133-140
        • Wyman JB
        • Dent J
        • Heddle R
        • Dodds WJ
        • Toouli J
        • Downton J.
        Control of belching by the lower oesophageal sphincter.
        Gut. 1990; 31: 639-646
        • Franzi SJ
        • Martin CJ
        • Cox MR
        • Dent J.
        Response of canine lower esophageal sphincter to gastric distension.
        Am J Physiol. 1990; 259: G380-G385