Real-time MRI for the dynamic assessment of fundoplication failure in patients with gastroesophageal reflux disease

Abstract

Purpose

To assess the diagnostic potential of dynamic real-time MRI for fundoplication failure in patients with persistent or recurrent GERD-like (gastroesophageal reflux disease) complaints.

Material and methods

Twenty-two consecutive patients (male n = 11; female n = 11; median age 59 years) with recurrent or persistent GERD-like symptom after fundoplication were enrolled between 2015 and 2017. Median duration of GERD-like symptoms was 21 months. Real-time MRI (3 Tesla) was performed at 40 ms temporal resolution using undersampled radial fast low-angle shot acquisitions with nonlinear inverse image reconstruction. MRI movies dynamically visualized bolus transit of pineapple juice through the gastroesophageal junction, position of the fundoplication wrap and recurring hernia or reflux during Valsalva maneuver. MRI results were compared to endoscopic findings.

Results

Real-time MRI was successfully completed in all patients without adverse events (average examination time 15 min). Morphological correlates for GERD-like symptoms were evident in 20 patients (90.1%) with gastric reflux in 19 cases. Nine patients (40.1%) had wrap disruption and recurrent gastric hernia. Wrap migration or telescoping hernia was detected in nine patients (40.1%). One patient presented with continued reflux despite intact fundoplication wrap. Esophageal dysmotility with delayed bolus passage was observed in one case. On endoscopy, gastric hernia or wrap disruption was diagnosed in seven cases, and esophagitis or Barret’s metaplasia in nine cases.

Conclusion

Real-time MRI is a fast and safe modality for dynamic imaging after fundoplication, without radiation exposure or administration of gadolinium-based contrast media. In a relevant number of cases, real-time MRI reveals correlates for GERD-like symptoms.

Key Points

• Real-time MRI reliably visualizes the gastroesophageal junction after fundoplication surgery.

• Patients with recurring GERD-like symptoms have a high rate of morphological failure patterns that can be identified by real-time MRI.

• Dynamic assessment of gastroesophageal junction by real-time MRI is a perspective diagnostic tool for detection of fundoplication failure.

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Abbreviations

GERD:

Gastroesophageal reflux disease

PPI:

Proton pump inhibitor

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Funding

The authors state that this work has not received any funding.

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Correspondence to Ali Seif Amir Hosseini.

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Guarantor

The scientific guarantor of this publication is Ali Seif Amir Hosseini.

Conflict of interest

Jens Frahm and Martin Uecker are co-inventors of a patent covering the real-time MRI technique used in this study.

Statistics and biometry

Statistical analyses were performed by a co-author with MPH degree.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• descriptive diagnostic study

• performed at one institution

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Electronic supplementary material

Real-time MRI (40 ms resolution) of the gastroesophageal junction during bolus passage (pineapple juice). Regular bolus transit while normal position of fundoplication wrap with expected bolus arrival in the distal esophagus on time and bolus transit through fundoplication wrap. Subsequently regular clearance of the distal esophagus. (M4V 26,502 kb)

Real-time MRI (40 ms resolution) of the gastroesophageal junction during bolus passage (pineapple juice), while the subject performs a Valsalva maneuver. During Valsalva maneuver parts of the stomach herniate through the fundoplication wrap. By the end of the video maximum extent of telescoping during Valsalva maneuver is reached. (M4V 28,208 kb)

Real-time MRI (40 ms resolution) of the gastroesophageal junction during bolus passage (pineapple juice), showing passage in sagittal planes. Video reveals delayed esophageal bolus transit and reduced propulsive peristalsis of the distal esophagus. The video indicates esophageal dysmotility with non-propulsive contractions and a considerably delayed incomplete esophageal clearance after 24 s. (M4V 49,209 kb)

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Seif Amir Hosseini, A., Uhlig, J., Streit, U. et al. Real-time MRI for the dynamic assessment of fundoplication failure in patients with gastroesophageal reflux disease. Eur Radiol 29, 4691–4698 (2019). https://doi.org/10.1007/s00330-019-06025-x

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Keywords

  • Magnetic resonance imaging
  • Gastroesophageal reflux disease (GERD)
  • Fundoplication