Fig. 14.1
Endoscopic evaluation of postfundoplicational alterations . (a) Properly positioned infradiaphragmatic fundoplication. (b) Intrathoracic fundoplication. (c) Disrupted infradiaphragmatic fundoplication. (d) Twisted infradiaphragmatic fundoplication. (e) Slipped fundoplication. (f) Paraesophageal hernia with a properly positioned fundoplication [8]
Fig. 14.2
(a) The HRM pressure topography of a patient with intact fundoplication. Compared to a healthy volunteer, the basal LES pressure is higher, but there is good LES relaxation during deglutition as the IRP is within normal limits. LES lower esophageal sphincter, IRP integrated relaxation pressure. Endoscopic picture reprinted from [4]. (b) Disrupted fundoplication. There is good relaxation with deglutition; however, the basal LES pressure is lower than in an intact fundoplication. LES lower esophageal sphincter. (c) The HPZ pressure pattern of a patient with a twisted fundoplication is shown in (c). One can see the high contractions and pressures in distal esophagus with high DCI and is indicative of outflow obstruction. These patients usually present with dysphagia or chest pain rather than reflux symptoms. LES lower esophageal sphincter, IRP integrated relaxation pressure, DCI distal contractile integral. (d) The HPZ pressure topography of an intact intra-thoracic fundoplication. In this patient, the HPZ is split into two: the distal HPZ represents the crus as the pattern indicates. The fundoplication is represented by the proximal HPZ. There is adequate pressure in the fundoplication with good relaxation as measured by a normal IRP. Such patients usually present with post-prandial chest/epigastric discomfort due to distention of herniated stomach. HPZ high pressure zone, IRP integrated relaxation pressure. (e) HRZ patterns in a patient with disrupted intra-thoracic fundoplication. The distal HPZ represents the crus. The proximal HPZ represents the area of the disrupted fundoplication. The basal LES pressure is low and there is a normal IRP. The low LES pressure indicates a disrupted fundoplication. HPZ high pressure zone, IRP integrated relaxation pressure, LES lower esophageal sphincter. Endoscopic picture reprinted from [4], with permission from Springer. (f) The HRZ patterns in a patient with slipped fundoplication. The proximal HPZ is the native LES and has low basal LES pressure with complete relaxation (normal IRP). The fundoplication is at the level of the crus. The diaphragmatic HPZ overlaps the fundoplication. HPZ high pressure zone, LES lower esophageal sphincter, IRP integrated relaxation pressure. Endoscopic pictures reprinted from [5], with permission from Springer. (g) Secondary achalasia is shown in g. These patients have aperistaltic esophageal body contractions. There is only a single HPZ pressure topography, but the LES pressure and the IRP are high. HPZ high pressure zone, LES lower esophageal sphincter, IRP integrated relaxation pressure. From Masato et al. [4]
14.3 How to Classify Failed Fundoplication?
Failed fundoplication have most commonly classified anatomically based on recurrence of hiatus hernia, relative location of the fundoplication to lower esophagus and geometry of the fundoplication. Jobe et al. [6] described in detail endoscopic characteristics of technically sound fundoplication and laid out the criteria for endoscopic assessment. However, majority of endoscopic assessment done in the community do not describe the fundoplication adequately. An audit of reported endoscopic findings by community gastroenterologists by Juhasz et al. [3] revealed a shockingly low concordance with subsequent findings of an experienced foregut surgeon. Surprisingly they found that nearly a 1/3rd of the endoscopic reports did not even mention a previous fundoplication while majority of the reports simply stated, “fundoplication changes noted” without any specific description. Proper and uniform endoscopic assessment of fundoplication is an import aspect in assessing causes of failure and devising a management strategy. Various terminologies have been used to describe failed fundoplication anatomy. Most commonly terms such as recurrent hiatus hernia, slipped, intra-thoracic, disrupted, twisted and telescopic fundoplication have been used. They have also been used interchangeably without accepted definitions. For example one may classify an intra-thoracic fundoplication is “slipped into the chest” or “telescoping in to the chest” while a fundoplication at the hiatus with GEJ above the hiatus may be called “ slipped below the GJ” or recurrent HH” or “misplaced fundoplication”.
Horagan et al. [7] were the first to propose an anatomic classification for failed fundoplication. They classified failed fundoplication into type IA (both EGJ and Fundoplication above the hiatus), type 1B (GEJ above hiatus with fundoplication below the hiatus, type II (only a portion of fundus/ greater curvature herniated above the hiatus) and type III ( body of the stomach used to create the wrap rather than the fundus) (Table 14.1). More recently a standardized system based on location of the GEJ relative to the hiatus, the fundoplication relative to the GEJ and geometry of the fundoplication has been proposed by Mittal et al. [8] (Table 14.2). Each of the component E, S, F and P are given a ‘suffix’ and final description is given as ExSxFxPx.
Type of failure | Description |
|---|---|
Type Ia | Both GEJ and fundoplication herniated above the hiatus |
Type Ib | GEJ above the hiatus and fundoplication at the hiatus |
Type II | Herniated stomach/greater curvature with GEJ and fundoplication below the hiatus |
Type III | Wrong part (body) of the stomach used for fundoplication |
Classification of the endoscopic findings of fundoplication | |
|---|---|
Type of failure | Description |
“E” component | Distance of GEJ to the level of crura component |
E 0 | GEJ is located intra-abdominally, at or under the level of crura |
E 1 | GEJ is located less than 2 cm above the level of crura |
E 2 | GEJ is located more than 2 cm above the level of crura |
“S” component | Amount of gastric tissue above the fundoplication and below the GEJ |
S 0 | Fundoplication is around the distal esophagus |
S 1 | Less than 2 cm gastric tissue above the fundoplication |
S 2 | More than 2 cm gastric tissue above the fundoplication |
“F” component | Description of the fundoplication |
F 0 | Intact fundoplication (competent, symmetrical) |
F 1a | Partially disrupted fundoplication |
F 1b | Completely disrupted fundoplication
Related posts: Anterior Versus Posterior Fundoplication, Are They Equal?
 Preoperative Diagnostic Workup for GERD and Hiatal Hernia: An Evidence and Experience-Based Approach
 Management of Recurrent Paraesophageal Hernia
 Preoperative Assessment of Failed Fundoplication with Recurrent Hiatal Hernia
 Laparoscopic Repair of Paraesophageal Hiatus Hernia: Suture Cruroplasty or Prosthetic Repair
 Quality of Life Following Laparoscopic Antireflux Surgery for Primary and Recurrent Gastroesophageal Reflux Disease
 Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
|