Endoscopic Assessment of a Prior Surgical Anti Reflux Procedure

Whereas in the past the postoperative assessment of a surgical anti-reflux repair was often made by using esophageal manometry to measure the LES length and pressure as an indicator of the competence of the postoperative valve, this has largely been supplanted by direct endoscopic assessment of the surgical repair. Much has since been written regarding the normal and disrupted endoscopic appearance of the various surgical anti-reflux procedures.21,31-33 However, many endoscopists continue to be unaware of the appearance of a normal, much less disrupted, anti-reflux surgery valve appearance or the technique of endo-scopic inspection or information that is needed by the treating physician in order to determine whether the wrap is functionally competent or has been compromised. It has been taught that the squamocolumnar junction usually approximates the proximal border of the lower esophageal sphincter and as such its location should be just above or within the surgical antireflux repair. When the location of the squamo-columnar junction is proximal to the wrap, this usually indicates a slipped or inappropriately placed repair. Additionally, the presence of esophagitis should be considered ample evidence of an incompetent repair and the return or persistence of reflux. Furthermore, on an endoscopic retroflexed view, it is expected that the wrap should appear to have a telescoping effect with the folds tightly adherent to the endoscope (Figures 10.1-10.5). Unfortunately, these various endoscopic findings are often subjectively appraised and not evaluated in a uniform or systematic way by the endoscopist attempting to assess the competency of a surgical anti-reflux repair.

Recently, a method to systematically endo-scopically appraise the appearance and function of the various surgical anti-reflux procedures has been described and physicians that deal with these patients need to be aware of this classification scheme in order to accurately appraise the integrity of the surgical repair and effectively communicate their findings to others caring for the patient31 (Table 10.1). In this proposed scheme, Jobe and colleagues31 have char-

Anti Reflux Toupet
Figure 10.1. Retroflexed endoscopic view of the normal postoperative appearance of a "Nissen"fundoplication.Note the thin lip, adequate length, tight adherence around the scope, and intraabdominal location.
Dor Fundoplication

Figure 10.2. Retroflexed endoscopic view of the appearance of a "slipped"Nissen fundoplication with the wrap and fundus her-niated across the diaphragm. Note the thicker than normal lip.

Table 10.1. Questions needing to be addressed during the endoscopic appraisal of a surgical antireflux procedure.

Figure 10.2. Retroflexed endoscopic view of the appearance of a "slipped"Nissen fundoplication with the wrap and fundus her-niated across the diaphragm. Note the thicker than normal lip.

1. What is the thickness of the lip of the valve?

2. What is the length of the valve?

3. What is the depth of the anterior and posterior grooves of the valve?

4. What is the width of the lesser curvature?

5. Is there close adherence of the valve to the endoscope during all phases of respiration?

6. Is it a flap or nipple valve?

7. Is the valve located intraabdominally?

8. Is the valve in the proper position relative to the esophagogastric junction?

9. Are the specific characteristics of that type of surgery evident?

Adapted from Jobe et al.31

Endoscopy Slipped Nissen

Figure 10.3. Retroflexed endoscopic view of a disrupted surgical anti-reflux repair with (A) valve laxity such that the retroflexed endoscope can be withdrawn (B) into the lower esophageal sphincter (LES) visualizing the squamocolumnar junction.

Figure 10.3. Retroflexed endoscopic view of a disrupted surgical anti-reflux repair with (A) valve laxity such that the retroflexed endoscope can be withdrawn (B) into the lower esophageal sphincter (LES) visualizing the squamocolumnar junction.

Antireflux Surgery

Figure 10.5. Retroflexed endoscopic view of a disrupted antireflux surgical repair with valve laxity, short intraabdominal length, and periesophageal hernia.

Figure 10.4. Retroflexed endoscopic view of a disrupted antireflux surgical repair with valve laxity, short intraabdominal length, etc.

Figure 10.5. Retroflexed endoscopic view of a disrupted antireflux surgical repair with valve laxity, short intraabdominal length, and periesophageal hernia.

THE MEDICAL AND ENDOSCOPIC MANAGEMENT OF FAILED SURGICAL PROCEDURES

acterized the normal "valve" appearance of the Nissen, Collis-Nissen, Toupet, Dor, and Hill anti-reflux surgical procedures and have suggested a common medical terminology that should be used to describe the appearance of the postsurgical repair. In this classification scheme, they used 10 criteria by which to judge the valve appearance and used this information to determine the competence of the surgical repair. Endoscopic valve criteria included the lip (thin vs broad), body (length in centimeters), anterior (absent, shallow, or deep), and posterior (absent, shallow, or deep) grooves, lesser curve appearance (narrow or wide), adherence to the scope on retroflexion (loose, moderate, or tight), effect of respiration (laxity at any time during respiration), valve "type" (flat or nipple), intraabdominal location being present as the normal finding,repair position 3 cm proximal to the gastroesophageal junction, and the unique appearance characteristics specific to each surgical repair. For instance, in the commonly performed Nissen procedure, they determined a normal postoperative valve should have a thin lip, 3- to 4-cm body, shallow anterior and deep posterior groove, narrow lesser curve, tight adherence to the scope at baseline and during respiration, nipple-type valve appearance, intraabdominal position, typical repair position, and a body appearing like a "stacked coil." Each of the various anti-reflux surgical procedures has its own unique endoscopic features that need to be appreciated in order to judge competency of the specific surgical repair with this endoscopic method. In the case in which the repair appears to be intact using these endo-scopic criteria, then serious consideration of alternative explanations for the patient's recurrent or persistent symptoms needs to undertaken. At a minimum, further physiological testing is now mandatory to prove reflux as a cause of the symptom (s). Hopefully, this carefully constructed endoscopic 10-item valve evaluation scheme can be demonstrated to be a reliable indicator of valve competency in prospective studies. Regardless, at this time, we believe that the above-described endoscopic evaluation of the valve remains the best initial test when evaluating a patient with suspected recurrent reflux after anti-reflux surgery before recommending further anti-reflux therapy of any sort.

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Responses

  • NEFTALEM
    What is a slipped nissen fundoplication?
    7 years ago
  • Kimberly
    Can squamocolumnar junction be repaired?
    7 years ago
  • nebay
    How wide the wrap should be nissen fundoplication?
    7 years ago
  • VERDIANA
    DOES A NISSEN WRAP THAT SLIPPED ABOVE THE GI JUNCTION NEED TO BE REPAIRED?
    6 years ago

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