Original Article
EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure

https://doi.org/10.1016/j.gie.2005.08.044Get rights and content

Background

In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication.

Methods

EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined.

Results

EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360° configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360° 5-layer pattern.

Conclusions

EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Section snippets

EUS of the native esophagogastric junction

Two swine, managed under the regulations of the Animal Care and Use Committee of the Oregon Health and Science University, underwent a 2-week acclimation period. Animals were fasted for 12 hours before the operation, and endotracheal anesthesia was maintained with 2.5% isoflurane and oxygen. At the conclusion of the procedures, the animals were euthanized with Euthasol, 1 mL per 4.5 kg.

Upper endoscopy with a 9.8-mm GIF140 endoscope (Olympus America Corp, Melville, NY) and EUS with a 7.5-MHz

Results

EUS images were interpreted in the context of the intrinsic and extrinsic anatomic relationships at the esophagogastric junction (Fig. 1). As the esophagus passes from the thoracic cavity to the abdominal cavity, it travels through the hiatus, which is created by the right and left bundles of the right crus and the anterior fusion of their muscle bundles. The hiatus is located to the left of midline, close to the posterior border of the central tendon of the diaphragm. From the level of the

Discussion

This pilot study has explored the use of EUS as a modality to image esophagogastric junction anatomy in the native state and after antireflux surgery. Our data demonstrate that EUS of hiatal anatomic relationships is feasible and provides useful information regarding the integrity of Nissen fundoplication and its relationship to the diaphragm.

The incidence of the various mechanisms of antireflux surgery failure vary significantly between studies (slipped, 3%-30%; dehiscence, 15%-30%;

Acknowledgments

We would like to thank Kevin Reavis, MD, and John Davis, MD, for their assistance with this study.

References (23)

  • P. Pessaux et al.

    Laparoscopic antireflux surgery: comparative study of Nissen, Nissen-Rossetti, and Toupet fundoplication. Societe Francaise de Chirurgie Laparoscopique

    Surg Endosc

    (2000)
  • Presented, in part, as an oral presentation at the 14th World Congress of the International Association of Surgeons and Gastroenterologists, September 8-11, 2004, Zurich, Switzerland.

    This work was supported, in part, by National Institutes of Health grants K23 DK066165-01 (B.A.J.), RO3 CA105959-01 (B.A.J.), RO1 DC00646 (P.J.K.), and the Society of American Gastrointestinal and Endoscopic Surgeons (B.A.J.).

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