Length and Pressure of the Reconstructed Lower Esophageal Sphincter is Determined by Both Crural Closure and Nissen Fundoplication
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Laparoscopic Nissen fundoplication is comprised of: a wrap thought responsible for the lower esophageal sphincter function and crural closure performed to prevent herniation. We hypothesized gastroesophageal junction competence effected by Nissen fundoplication results from closure of the crural diaphragm and creation of the fundoplication.
Patients with uncomplicated reflux undergoing Nissen fundoplication were prospectively enrolled. After hiatal dissection, patients were randomized to crural closure followed by fundoplication (group 1) or fundoplication followed by crural closure (group 2). Intra-operative high-resolution manometry collected sphincter pressure and length data after complete dissection and after each component repair.
Eighteen patients were randomized. When compared to the completely dissected hiatus, the mean sphincter length increased 1.3 cm (p < 0.001), and mean sphincter pressure was increased by 13.7 mmHg (p < 0.001). Groups 1 and 2 had similar sphincter length and pressure changes. Crural closure and fundal wrap contribute equally to sphincter length, although crural closure appears to contribute more to sphincter pressure.
The Nissen fundoplication restores the function of the gastroesophageal junction and thus the reflux barrier by means of two main components: the crural closure and the construction of a 360° fundal wrap. Each of these components is equally important in establishing both increased sphincter length and pressure.
KeywordsDiaphragm Fundoplication GERD Hiatal hernia Manometry Lower esophageal sphincter
- 3.Lundell L, Miettinen P, Myrvold HE, Hatlebakk JG, Wallin L, Engström C, et al. Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2009 Dec;7(12):1292–8; quiz 1260.Google Scholar
- 4.Attwood SE a, Lundell L, Ell C, Galmiche J-P, Hatlebakk J, Fiocca R, et al. Standardization of surgical technique in antireflux surgery: the LOTUS Trial experience. World Journal of Surgery. 2008 Jun;32(6):995–8Google Scholar
- 5.DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Annals of Surgery. 1986 Jul;204(1):9–20.Google Scholar
- 6.Pandolfino JE, Curry J, Shi G, Joehl RJ, Brasseur JG, Kahrilas PJ. Restoration of Normal Distensive Characteristics of the Esophagogastric Junction After Fundoplication. Annals of Surgery. 2005 Jul;242(1):43–8.Google Scholar
- 7.Ayazi S, Tamhankar A, DeMeester SR, Zehetner J, Wu C, Lipham JC, et al. The impact of gastric distension on the lower esophageal sphincter and its exposure to acid gastric juice. Annals of Surgery. 2010 Jul;252(1):57–62.Google Scholar
- 8.Watson DI, Jamieson GG, Devitt PG, Mitchell PC, Game PA. Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication. The British Journal of Surgery. 1995 Apr;82(4):521–3.Google Scholar
- 9.Louie B, Blitz M, Farivar A, Orlina J, Aye RW. Repair of Symptomatic Giant Paraesophageal Hernias in Elderly (> 70 Years) Patients Results in Improved Quality of Life. Journal of Gastrointestinal Surgery. 2011;:1–8.Google Scholar
- 10.Kahrilas PJ, Lin S, Manka M, Shi G, Joehl RJ. Esophagogastric junction pressure topography after fundoplication. Surgery. 2000 Feb;127(2):200–8.Google Scholar
- 11.O’Sullivan GC, DeMeester TR, Joelsson BE, Smith RB, Blough RR, Johnson LF, et al. Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastroesophageal competence. American Journal of Surgery. 1982 Jan;143(1):40–7.Google Scholar
- 12.Samelson SL, Weiser HF, Bombeck CT, Siewert JR, Ludtke FE, Hoelscher AH, et al. A new concept in the surgical treatment of gastroesophageal reflux. Annals of Surgery. 1983 Mar;197(3):254–9.Google Scholar
- 13.Ganz RA, Gostout CJ, Grudem J, Swanson W, Berg T, DeMeester TR. Use of a magnetic sphincter for the treatment of GERD: a feasibility study. Gastrointestinal Endoscopy. 2008 Feb;67(2):287–94.Google Scholar
- 14.Mittal RK, Rochester DF, McCallum RW. Electrical and mechanical activity in the human lower esophageal sphincter during diaphragmatic contraction. The Journal of Clinical Investigation. 1988 Apr;81(4):1182–9.Google Scholar
- 15.Mittal RK, Rochester DF, McCallum RW. Sphincteric action of the diaphragm during a relaxed lower esophageal sphincter in humans. The American Journal of Physiology. 1989 Jan;256(1 Pt 1):G139–44.Google Scholar
- 16.Hoppo T, Immanuel A, Schuchert M, Dubrava Z, Smith A, Nottle P, et al. Transoral incisionless fundoplication 2.0 procedure using EsophyXTM for gastroesophageal reflux disease. Journal of Gastrointestinal Surgery. 2010 Dec;14(12):1895–901Google Scholar
- 17.Bell RCW, Freeman KD. Clinical and pH-metric outcomes of transoral esophagogastric fundoplication for the treatment of gastroesophageal reflux disease. Surgical Endoscopy. 2011 Jun;25(6):1975–84.Google Scholar
- 18.Granderath FA, Schweiger UM, Kamolz T, Pointner R. Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap. Surgical Endoscopy. 2005 Nov;19(11):1439–46.Google Scholar
- 19.Ayazi S, Hagen JA, Zehetner J, Ross O, Wu C, Oezcelik A, et al. The value of high-resolution manometry in the assessment of the resting characteristics of the lower esophageal sphincter. Journal of Gastrointestinal Surgery. 2009 Dec;13(12):2113–20.Google Scholar