Impact of fundoplication on bolus transit across esophagogastric junction

Abstract

This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.

Dysphagia and Gastroesophageal Junction Resistance to Flow Following Partial and Total Fundoplication

“…Further, we found that the circumferential extent of the fundal wrap significantly influenced intrabolus pressure and residual GEJ relaxation pressure. Many previous studies have concentrated on findings for one type of operation such as total fundoplication 5,18,19 or inappropriately focused on GEJ resting pressure. GEJ relaxation can only be reliably recorded with a sleeve or with pressure sensors spaced at no more than 1 cm intervals.…”

“…We propose that the esophagus adapts to increased GEJ resistance to flow by generating higher esophageal contraction pressures and that limits in this adaptive response may result in impaired bolus transit, 6,19 and dysphagia. 21 Scheffer et al 18 have proposed that greater esophageal contraction strength is necessary to overcome increased GEJ resistance after fundoplication.…”

Laparoscopic vs open approach for Nissen fundoplication

“…Several local anatomical and functional factors-including tissue stretching and edema and inflammation of the esophagus leading to impaired motility [10], increased yield pressure upon the LES [15], increased nadir LES pressure on swallowing [9], increased esophageal ramp pressure on swallowing [2], and distortion of the distal esophageal segment [12]-have all been implicated in the pathogenesis of the symptom, although correlation of these findings with clinical dysphagia has not yet been confirmed [25]. In the present study, we did not address the possible mechanisms of postfundoplication dysphagia.…”

Post-fundoplication contrast studies: is there room for improvement?

“…Assessment of hold-up of contrast in the early postoperative period may be difficult owing to oedema at the GOJ and oesophageal ileus from surgical manipulation [21]. Patients are therefore kept on a specific diet (avoiding foods that may cause a bolus obstruction) for up to 6 weeks [10,22,23]. As such, hold-up of contrast is to be expected and, as far as the surgeon is concerned, any flow of contrast beyond the junction is usually sufficient in the early post-operative period.…”