Figure 42-34. Combined multichannel intraluminal impedance–pH catheter. (Reproduced with permission from Mainie I, Tutuian

R, Agrawal A, et al. Combined multichannel intraluminal impedance-pH monitoring to select patients with persistent gastrooesophageal reflux for laparoscopic Nissen fundoplication. Br J Surg 2006;93:1483–1487.)

Combined MII-pH monitoring has recently been used to select patients, both with typical and atypical

manifestations of GERD and who are resistant to medical treatment, for fundoplication.171 Patients with

a positive symptom index, as assessed by combined MII-pH testing while on PPI therapy, were noted to

respond well to surgery. Another recent trial demonstrated that combined MII-pH testing is more

accurate for the preoperative assessment of GERD in patients off of PPI therapy compared to pH

monitoring alone.172

Assessment of Esophageal Length. Esophageal shortening is a consequence of scarring and fibrosis

associated with repetitive esophageal injury. Anatomic shortening of the esophagus can compromise the

ability to perform an adequate tension-free fundoplication and may result in an increased incidence of

breakdown or thoracic displacement of the repair. Esophageal length is best assessed preoperatively

using video roentgenographic contrast studies and endoscopic findings. Endoscopically, hernia size is

measured as the difference between the diaphragmatic crura, identified by having the patient sniff, and

the GE junction, identified as the loss of gastric rugal folds. We consider the possibility of a short

esophagus in patients with strictures or those with large hiatal hernias (>5 cm), particularly when the

latter fail to reduce in the upright position on a video barium esophagram.173

The definitive determination of esophageal shortening is made intraoperatively when, after thorough

mobilization of the esophagus, the GE junction cannot be reduced below the diaphragmatic hiatus

without undue tension on the esophageal body. Surgeons performing fundoplication have reported

varying incidences of esophageal shortening, attesting to the judgment inherent in defining and

recognizing “undue tension.” An advantage of transthoracic fundoplication is the ability to mobilize the

esophagus extensively from the diaphragmatic hiatus to the aortic arch. With the GE junction marked

with a suture, esophageal shortening is defined by an inability to position the repair beneath the

diaphragm without tension. In this situation, a Collis gastroplasty coupled with either a partial or

complete fundoplication may be performed.174

Potential pitfalls of laparoscopic fundoplication include the elevation of the diaphragm due to

pneumoperitoneum, potentially contributing to a false impression that esophageal length is adequate,

and the limited ability to mobilize the esophagus relative to the transthoracic approach.175 In our

experience, the failure to appreciate esophageal shortening is a major cause of fundoplication failure

and is often the explanation for the “slipped” Nissen fundoplication. In many such instances, the initial

repair is incorrectly constructed around the proximal tubularized stomach rather than the terminal

esophagus. Surgeons opting to perform fundoplication laparoscopically in the setting of potential

esophageal shortening must be vigilant of esophageal tension, technically facile at extensive mediastinal

mobilization of the esophagus while preserving vagal integrity, and able to perform a laparoscopic or

open transabdominal Collis gastroplasty should esophageal lengthening be necessary.

Radiographic Evaluation. Radiographic assessment of the anatomy and function of the esophagus and

stomach is one of the most important parts of the preoperative evaluation. Critical issues are assessed,

including the presence of esophageal shortening (Fig. 42-35), the size and reducibility of a hiatal hernia,

and the propulsive function of the esophagus for both liquids and solids.

The definition of radiographic GE reflux varies depending on whether reflux is spontaneous or

1080

induced by various maneuvers. In only about 40% of patients with classic symptoms of GERD is

spontaneous reflux observed by the radiologist (i.e., reflux of barium from the stomach into the

esophagus with the patient in the upright position). In most patients who show spontaneous reflux on

radiography, the diagnosis of increased esophageal acid exposure is confirmed by 24-hour esophageal

pH monitoring. Therefore, the radiographic demonstration of spontaneous regurgitation of barium into

the esophagus in the upright position is a reliable indicator that reflux is present. On the contrary,

failure to see radiographic reflux does not prove the absence of reflux disease.

Figure 42-35. Barium-filled esophagogastric segment in a patient with a short esophagus. Note that the gastroesophageal junction

is well above the hiatus.

DIAGNOSIS

Table 42-7 University of Southern California Protocol for Video Esophagram

Studies

A carefully performed video esophagram can provide an enormous amount of information on the

structure and function of the esophagus and stomach. The modern barium swallow emphasizes motion

recording (video), utilizes a tightly controlled examination protocol (Table 42-7), and requires an

understanding of esophageal physiology.

Videotaping the study greatly aids the evaluation, providing the surgeon with a real-time assessment

of swallowing function, bolus transport, and the size and reducibility of an associated hiatal hernia.

Given routine review before antireflux surgery, the value of the study becomes increasingly clear. The

examination provides structural information including the presence of obstructing lesions and anatomic

1081

abnormalities of the foregut. A hiatal hernia is present in more than 80% of patients with GE reflux and

is best demonstrated with the patient in the prone position, which causes increased abdominal pressure

and promotes distention of the hernia above the diaphragm. The presence of a hiatal hernia is an

important component of the underlying pathophysiology of GE reflux. Other relevant findings include a

large (>5 cm) or irreducible hernia, suggesting the presence of a shortened esophagus; a tight crural

“collar” that inhibits barium transit into the stomach, suggesting a possible cause of dysphagia; and the

presence of a PEH.

Lower esophageal narrowing resulting from a ring, stricture, or obstructing lesion is optimally viewed

with full distention of the esophagogastric region. A full-column technique with distention of the

esophageal wall can be used to discern extrinsic compression of the esophagus. Mucosal relief or doublecontrast films should be obtained to enhance the detection of small esophageal neoplasms, mild

esophagitis, and esophageal varices. The pharynx and UES are evaluated in the upright position, and an

assessment of the relative timing and coordination of pharyngeal transit is possible.

The assessment of peristalsis on video esophagram often adds to, or complements, the information

obtained by esophageal motility studies. This is in part because the video barium study can be done

both upright and supine and with liquid and solid bolus material, which is not true of a stationary

motility examination. This is particularly true with subtle motility abnormalities. During normal

swallowing, a stripping wave (primary peristalsis) is generated that completely clears the bolus.

Residual material can stimulate a secondary peristaltic wave, but usually a second pharyngeal swallow

is required. Motility disorders with disorganized or simultaneous esophageal contractions have “tertiary

waves” and provide a segmented appearance to the barium column, often referred to as beading or

corkscrewing. In dysphagic patients, a barium-impregnated marshmallow, bread, or hamburger is a

useful adjunct, which can discern a functional esophageal transport disturbance not evident on the liquid

barium study. Reflux is not easily seen on video esophagram, and motility disorders that cause

retrograde barium transport may be mistaken for reflux.

Assessment of the stomach and duodenum during the barium study is a necessity for proper

preoperative evaluation of the patient with GERD. Evidence of gastric or duodenal ulcer, neoplasm, or

poor gastroduodenal transit has obvious importance in the proper preoperative evaluation.

Assessment of Esophageal Function. The presence of poor esophageal body function can impact the

likelihood of relief of regurgitation, dysphagia, and RSs following surgery and may influence the

decision to undertake a partial rather than a complete fundoplication. When peristalsis is absent or

severely disordered, many surgeons would opt for a partial fundoplication, although recent studies

would suggest a complete fundoplication may be appropriate even in this setting. The less favorable

response of atypical, compared with typical, reflux symptoms after fundoplication may be related to

persistent poor esophageal propulsive function and the continued regurgitation of esophageal

contents.176,177

The function of the esophageal body is assessed with esophageal manometry. Conventional waterperfused or solid-state manometry is performed with five pressure transducers located in the esophagus

(Fig. 42-36). To standardize the procedure, the most proximal pressure transducer is located 1 cm below

the well-defined cricopharyngeal sphincter. With this method, a pressure response along the entire

esophagus can be obtained during one swallow. The study consists of recording 10 wet swallows with 5

mL of water. Amplitude, duration, and morphology of contractions following each swallow are all

calculated at the five discrete levels within the esophageal body (Fig. 42-37). The delay between onset

or peak of esophageal contractions at the various levels of the esophagus is used to calculate the speed

of wave propagation and represents the degree of peristaltic activity.

1082

Figure 42-36. Illustration of the position of a five-channel esophageal motility catheter during the esophageal body portion of the

study.

Recently, HRM (ManoScan360, Sierra Scientific Instruments, Los Angeles, CA) has been introduced

into clinical practice and may possess several advantages over the other manometric systems currently

available.178 The high-resolution catheter is 4.2 mm in diameter and has 36 solid-state transducers

spaced at 1-cm intervals, compared to the standard 3- to 5-cm spacing of traditional water-perfused or

solid-state catheters. Pressure transduction technology allows each of the sensors to detect pressure over

a length of 2.5 mm in 12 radially dispersed sectors. The pressure of each sector is averaged, making

each of the 36 sensors a circumferential pressure detector. This construct allows a more thorough and

precise evaluation of esophageal function than standard manometry. In addition, given the number and

span of transducers across the length of the catheter, the UES, esophageal body, and lower esophageal

sphincter can be assessed simultaneously without moving the catheter. Thus, the study can be

performed more quickly and with improved patient comfort compared to conventional manometry in

that multiple repositionings of the catheter are not required to complete the evaluation. The experience

in our laboratory has been that HRM takes, on average, only 8.1 minutes to complete, whereas standard

manometry with a solid-state catheter takes 24.4 minutes (p < 0.0001).141 Finally, the color-coded

readouts allow for a better, more intuitive, graphic description of the motor activity of the esophagus,

the characteristics of the lower esophageal sphincter, and the presence of a hiatal hernia compared to

the other technologies (Fig. 42-38). The catheter, however, is expensive with a high replacement cost

should it break. With increasing experience and further study, the pros and cons of this new technology

will continue to be elucidated.

Assessment of Gastric Function. Esophageal disorders are frequently associated with abnormalities of

duodenogastric function. Symptoms suggestive of gastroduodenal pathology include nausea, epigastric

pain, anorexia, and early satiety. Abnormalities of gastric motility or increased gastric acid secretion can

be responsible for increased esophageal exposure to gastric juice. If not identified before surgery,

unrecognized gastric motility abnormalities are occasionally “unmasked” by an antireflux procedure,

resulting in disabling postoperative symptoms.43 Considerable experience and judgment are necessary to

identify the patient with occult gastroduodenal dysfunction. The surgeon should maintain a keen

awareness of this possibility and investigate the stomach given any suggestion of problems. Tests of

duodenogastric function that are helpful when investigating the patient with GE reflux include gastric

emptying studies, gastric acid analysis, 24-hour gastric pH monitoring, and ambulatory bilirubin

monitoring of the esophagus and stomach.

1083