Surgical Endoscopy

, 25:3198 | Cite as

Postprandial proximal gastric acid pocket in patients after laparoscopic Nissen fundoplication

  • Fernando A. M. HerbellaEmail author
  • Fernando P. P. Vicentine
  • Jose C. Del Grande
  • Marco G. Patti



An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in normal individuals and patients with gastroesophageal reflux disease (GERD). The role of gastric anatomy in the physiology of the PPGAP remains unclear. It is also unclear whether change in the PPGAP may contribute to GERD control. This study aims to analyze the presence of PPGAP in patients submitted to Nissen fundoplication.


Fifteen patients who had a laparoscopic Nissen fundoplication (mean age = 61 years, 13 females, mean time from operation 1 year) were studied. All patients were free of foregut symptoms. Patients underwent high-resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES).Station pull-through pH monitoring was performed from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal.


Four patterns of gastric acidity were found: (1) acid was not detected in the studied area of the stomach in 8 (53%) patients; (2) constant acidity (stomach is not alkalinized after meal), i.e., a buffered layer was not found in 3 (20%) patients; (3) PPGAP was not detected, i.e., the whole stomach is alkalinized, in 1 (7%) patient; and (4) PPGAP was noted in 3 (20%) patients with extensions of 2, 2, and 5 cm.


PPGAP is present in a minority of patients after Nissen fundoplication. This finding may explain part of the GERD control and that the gastric fundus may play a role in the genesis of the PPGAP.


Gastroesophageal reflux Acid pocket Nissen fundoplication 



We are indebted to Ms. Mirian Wolfarth for her invaluable technical assistance with the esophageal tests. This study was supported by the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) grant No. 2007/07940-8.


F. A. M. Herbella, F. P. P. Vicentine, J. C. Del Grande, and M. G. Patti have no conflicts of interest or financial ties to disclose.


  1. 1.
    Meneghetti AT, Tedesco P, Galvani C, Gorodner MV, Patti MG (2008) Outcomes after laparoscopic Nissen fundoplication are not influenced by the pattern of reflux. Dis Esophagus 21(2):165–169PubMedCrossRefGoogle Scholar
  2. 2.
    Lord RV, DeMeester SR, Peters JH, Hagen JA, Elyssnia D, Sheth CT, DeMeester TR (2009) Hiatal hernia, lower esophageal sphincter incompetence, and effectiveness of Nissen fundoplication in the spectrum of gastroesophageal reflux disease. J Gastrointest Surg 13(4):602–610PubMedCrossRefGoogle Scholar
  3. 3.
    Herbella FA, Patti MG (2010) Gastroesophageal reflux disease: from pathophysiology to treatment. Word J Gastroenterol 16(30):1–5Google Scholar
  4. 4.
    Herbella FA, Vicentine FP, Del Grande JC (2010) High-resolution and conventional manometry in the assessment of the lower esophageal sphincter length. J Gastrointest Surg14(9):1466-1467; author reply 1468-1469Google Scholar
  5. 5.
    Fletcher J, Wirz A, Young J, Vallance R, McColl KE (2001) Unbuffered highly acidic gastric juice exists at the gastroesophageal junction after a meal. Gastroenterology 121(4):775–783PubMedCrossRefGoogle Scholar
  6. 6.
    Mason RJ, Oberg S, Bremner CG, Peters JH, Gadenstätter M, Ritter M, DeMeester TR (1998) Postprandial gastroesophageal reflux in normal volunteers and symptomatic patients. J Gastrointest Surg 2(4):342–349PubMedCrossRefGoogle Scholar
  7. 7.
    Barlow AP, Hinder RA, DeMeester TR, Fuchs K (1994) Twenty-four-hour gastric luminal pH in normal subjects: influence of probe position, food, posture, and duodenogastric reflux. Am J Gastroenterol 89:2006–2010PubMedGoogle Scholar
  8. 8.
    Holloway RH, Sifrim DA (2008) The acid pocket and its relevance to reflux disease. Gut 57(3):285–286PubMedCrossRefGoogle Scholar
  9. 9.
    Herbella FA, Vicentine FP, Del Grande JC, Patti MG (2011) Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery. Neurogastroenterol Motil 23(1):52–55 e4PubMedCrossRefGoogle Scholar
  10. 10.
    Herbella FA, Vicentine FP, Del Grande JC, Patti MG, Arasaki CH (2010) Postprandial proximal gastric acid pocket in patients after Roux-en-Y gastric bypass. J Gastrointest Surg 14(11):1742–1745PubMedCrossRefGoogle Scholar
  11. 11.
    Pandolfino JE, Zhang Q, Ghosh SK, Post J, Kwiatek M, Kahrilas PJ (2007) Acidity surrounding the squamocolumnar junction in GERD patients: “acid pocket” versus “acid film”. Am J Gastroenterol 102(12):2633–2641PubMedCrossRefGoogle Scholar
  12. 12.
    Beaumont H, Bennink RJ, de Jong J, Boeckxstaens GE (2010) The position of the acid pocket as a major risk factor for acidic reflux in healthy subjects and patients with GORD. Gut 59(4):441–451PubMedCrossRefGoogle Scholar
  13. 13.
    Myers JC, Jamieson GG, Wayman J, King DR, Watson DI (2007) Esophageal ileus following laparoscopic fundoplication. Dis Esophagus 20(5):420–427PubMedCrossRefGoogle Scholar
  14. 14.
    Rocha SL, Souza Filho ZA, Borges FF, Stroparo G, Grippa MM, Gonçalves PCZ (2004) Experimental model of gastric-esophageal fundoplication in rats: manometric and histological study of the esophagus. Acta Cir Bras 19(2):141–145CrossRefGoogle Scholar
  15. 15.
    Clarke AT, Wirz AA, Manning JJ, Ballantyne SA, Alcorn DJ, McColl KE (2008) Severe reflux disease is associated with an enlarged unbuffered proximal gastric acid pocket. Gut 57(3):292–297PubMedCrossRefGoogle Scholar
  16. 16.
    Vo L, Simonian HP, Doma S, Fisher RS, Parkman HP (2005) The effect of rabeprazole on regional gastric acidity and the postprandial cardia/gastro-oesophageal junction acid layer in normal subjects: a randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther 21(11):1321–1330PubMedCrossRefGoogle Scholar
  17. 17.
    Morgan D, Pandolfino J, Katz PO, Goldstein JL, Barker PN, Illueca M (2010) Clinical trial: gastric acid suppression in Hispanic adults with symptomatic gastroesophageal reflux disease—comparator study of esomeprazole, lansoprazole, and pantoprazole. Aliment Pharmacol Ther 32(2):200–208PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Fernando A. M. Herbella
    • 1
    • 3
    Email author
  • Fernando P. P. Vicentine
    • 1
  • Jose C. Del Grande
    • 1
  • Marco G. Patti
    • 2
  1. 1.Department of Surgery, Escola Paulista de MedicinaFederal University of São PauloSão PauloBrazil
  2. 2.Department of SurgeryUniversity of ChicagoChicagoUSA
  3. 3.Division of Esophagus and StomachHospital Sao Paulo, Surgical GastroenterologySao PauloBrazil

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