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R. A. Saavedra and E. Auyang
Upper GI/Esophagram
UGI is a powerful tool in assessing esophageal and gastric anatomy. Images can be obtained in upright, oblique, and supine positions and can also dynamically evaluate function by observing
contrast ow in real-time and passage of a radiolucent tablet during a swallow. While the anatomic and functional information that
these studies provide in the preoperative evaluation of a hiatal hernia is valuable, routine use in the postoperative evaluation of
asymptomatic patients is not required [1]. However, postoperative
contrast studies are still obtained by some providers to evaluate
for leak immediately post-procedure or to evaluate the anatomic
results [2, 3].
After hiatal hernia repair and fundoplication, contrast imaging
should show a smooth, tapered narrowing of the distal esophagus
and GEJ with a 2–3 cm wrap seen below the level of the diaphragm (Fig.26.1) [2, 4, 5]. There should not be any evidence of
hernia recurrence or reux. Immediately postoperatively, there
may be evidence of swelling near the fundoplication due to tissue
edema. However, this swelling should not interfere with passage
of radio-opaque material or cause any signicant esophageal dilation proximally (Fig. 26.2). When visualized, the leaves of the
fundoplication will appear as blind ends surrounding the esophagus. The anterior leaf of the fundoplication may not be visualized
as it is challenging to reux contrast into this area [4]. Patient
positioning should be veried as the fundal wrap defect may form
an acute angle created by the plication and the nonsurgical gastric
wall when the patient is supine [5]. It is important to know the
surgical procedure performed as the type of fundoplication performed may alter interpretation of imaged results. For example, a
Toupet or Dor fundoplication may be misinterpreted as a disrupted fundoplication. If an esophageal lengthening procedure
was necessary, the presence of gastric folds within the wrap is
expected.
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Fig. 26.1 Normal UGI showing contrast easily passing through an intact
fundoplication into stomach
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R. A. Saavedra and E. Auyang
Fig. 26.2 Normal UGI from a lateral perspective showing an intact wrap
with contrast entering the leaets of the fundoplication
Computed Tomography
CT imaging may be obtained for various reasons in patients postfundoplication. The patient may be symptomatic from the wrap
itself, or the wrap may be incidentally seen during evaluation of
another anatomical pathology. Similar to the discussion of UGI,
understanding the performed surgical procedure and subsequent
expected anatomy is critical to proper interpretation of CT imaging.
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Fig. 26.3 CT scan showing leaets of the fundoplication wrapping around
the distal esophagus
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Imaging should clearly show the gastric fundus wrapped
around the distal esophagus. Again, the GEJ will lie below the
diaphragm with a 2–3 cm wrap surrounding it (Fig. 26.3). No
evidence of hernia recurrence should be present. Gaseous distension of the body and fundus of the stomach do not suggest underlying pathology and should still permit for proper fundoplication
evaluation [6]. In the rst several weeks postoperatively, thickening of the gastric mucosa at the fundoplication secondary to
edema is expected [6]. If contrast is used, it ought to pass through
the fundoplication easily and there should not be signicant
esophageal dilation. A slight “whirled” appearance of the fundoplication is within normal limits [5]. As discussed above, Toupet
or Dor fundoplication may again appear as a disrupted fundoplication on CT and so reference to the original procedure should be
made when possible.
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R. A. Saavedra and E. Auyang
Manometry andMotility
There is extensive literature regarding evaluation of the physiology of the esophagus in the preoperative and postoperative settings. Esophageal manometry allows for assessment of global
motility as well as the subcomponents of the esophagus. It is not
typically conducted on a routine basis after fundoplication as its
association with symptomatology has been controversial. The
normal pressures produced by the esophagus in the asymptomatic patient can vary widely [7]. Hiatal hernia repair and fundoplication do not affect the physiologic function of the esophagus
and are not associated with motility changes in the esophageal
body [8]. Therefore, peristaltic function is expected to be
unchanged due to a repair and fundoplication. The lower esophageal sphincter (LES) may see some change in pressures.
Patients’ LES resting pressures tend to be lower preoperatively,
with mean pressure ranging from 6 to 16 mmHg [8–10].
Postoperatively, there is a statistically signicant increase in
mean pressures, with a range of 17–24 mmHg [8–10]. These
changes are expected and are not associated with symptomatology such as dysphagia.
pH Testing
pH testing is typically performed using catheter-based pH monitoring or the portable BRAVO system. This testing evaluates for
reux and can be clinically correlated to the patient’s symptoms.
Similar to manometry, pH testing is not routinely done in asymptomatic patients postoperatively. However, pH testing has been
used for objective conrmation of surgical success in postoperative patients via examination of time with pH <4.0 and DeMeester
score. Preoperatively, patients have an increased time with a pH
<4.0 in the esophagus compared to normal and a DeMeester
score>14.7 which indicates abnormally high amount of reux
[9, 10]. The anatomical restoration of the LES provided by fun-
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doplication improves both of these metrics. Postoperatively,
patients should experience a normalization of DeMeester score
to <14.7 and the time of pH <4.0 decreases to ≤5.5% of the time
on 24-hr evaluation [9, 10]. These results have also been seen in
BRAVO pH analysis. This analysis reiterates decreased reux
episodes, decreased percentage time with pH<4.0, and signicant improvements in DeMeester score to as low as 1.25in postoperative patients [11]. Those who undergo giant hiatal hernia
repair in addition to fundoplication will show the same normalization of DeMeester score and percentage time pH<4.0, though
the objective data may show slightly more episodes of reux
compared to fundoplication alone [12]. These data do not correlate with any clinically signicant change in patient symptomatology and is still within normal limits of objective ndings. If
patients have recurrent or atypical symptoms postoperative, the
pH study can be used as a test to rule out GERD as an etiology
especially when symptoms do not correlate with objective episodes of reux.
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Endoscopy
Endoscopy is standard in the evaluation of upper gastrointestinal
tract pathology, including hiatal hernia evaluation in the preoperative setting. It can also be utilized postoperatively to evaluate the
integrity of hiatal hernia repair and fundoplication. It is important
to understand endoscopic ndings in both settings. The Hill classication is a grading system that has been utilized for evaluation
of hiatal hernias. Its principles can be used in both pre- and postoperative settings to evaluate the gastroesophageal ap [13]. Hill
classication grades the valve integrity from I-IV.Grade I shows
a prominent fold of gastric tissue directly against the endoscope.
As the grades increase, the evidence of the gastroesophageal ap
is less apparent and the tissue no longer approximates the scope.
Grade IV will show an open esophageal lumen and an obvious
hiatal hernia. Appropriate surgical repair should reapproximate
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Fig. 26.4 Endoscopy showing an intact Nissen fundoplication
R. A. Saavedra and E. Auyang
the normal anatomy; however, it is important to reiterate that anatomy visualized on endoscopic evaluation is dependent on the specic repair used.
For example, Nissen fundoplication will lead to creation of a
nipple valve on endoscopy with a deep posterior and shallow
anterior groove (Fig.26.4) [14]. The valve will have an “omega”
shape to it and should closely approximate the endoscope.
Similarly, a Toupet fundoplication will have a ap valve in an
“omega” shape and may look identical to that of a Nissen fundoplication (Fig.26.5) [14]. Lastly, a Dor fundoplication will have a
ap valve that is wide and “S”-shaped and should moderately
approximate the scope [14]. Regardless of the operative technique
used, the gastroesophageal ap should closely approximate the
scope, thus resembling a Hill grade I without evidence of a recurrent hiatal hernia.
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Fig. 26.5 Endoscopy showing an intact Toupet fundoplication
Gastric Emptying
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Gastric emptying is usually measured over 2–4h using Tc-99 sulfur colloid foods. Normal values are 10% emptying at 1hr., 65%
at 2h, and 90% at 4h [15]. Delayed gastric emptying is uncommon after surgery; however, it is more commonly reported in
cases after very large hiatal hernia repairs or redo paraesophageal
hernia repairs [16, 17], likely from gastric atony and not true gastroparesis. Hiatal hernia repair with fundoplication should not
result in worsened gastric emptying. The vagus nerve should be
left intact during the operation. Thus, vagal nerve function and
gastric emptying should be preserved. The restoration of a more
normal anatomy can potentially even improve gastric emptying in
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those with preoperative delayed gastric emptying [18, 19].
Overall, gastric emptying should be expected to have normal
results postoperatively in the absence of preexisting gastroparesis.
R. A. Saavedra and E. Auyang
EndoFLIP
Endoluminal functional luminal-imaging probe (EndoFLIP) is a
newer technology that can be used to assess GEJ function, measuring its diameter, area, pressure, and distensibility. EndoFLIP
has been used intraoperatively to tailor fundoplications, and its
use has shown that a drop in the distensibility index (DI) is associated with nonrecurrence of symptoms in short-term follow-up
[20]. Fundoplication will generally reduce the DI as the intervention is decreasing the cross-sectional area of the GEJ.The type of
fundoplication used may vary the degree of DI reduction [21].
Exact numeric values identifying a functional fundoplication are
still lacking due to the recent introduction of this device. One
study has suggested that minimal diameter changes of <0.15mm
and cross-sectional area changes of <1.5mm^2 may lead to recurrence of symptoms [22]. EndoFLIP may prove a valuable tool in
determining the adequacy of fundoplication and tailoring repairs
for patients. However, further data are needed to clarify what
measurements or changes can be veried as normal for the patient.
Discussion
Hiatal hernia repair with fundoplication should recreate normal
anatomy, and thus restore the physiologic function of the
GEJ. When performing postoperative testing, reference to the
original operation helps delineate what ndings are expected,
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especially with image-directed studies looking at the anatomy.
With physiologic testing, such as manometry, pH testing, and gastric emptying, ndings should be similar to those of an asymptomatic patient. Normal physiologic ndings suggest that
reoperation will not benet the patient. Signicant deviation from
ndings discussed here should be viewed as abnormal. However,
abnormal ndings alone do not necessarily indicate a need for
operative repair. Correlation to symptoms needs to be established.
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Editors’ Note
Reux/Dysphagia After aSleeve
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