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Open Nissen Fundoplication Laboratory Medicine

  • Author: Nicole E Sharp, MD; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS  more...
 
Updated: Feb 27, 2015
 
 

Laboratory Medicine Summary

Esophagogastroduodenoscopy

Esophagogastroduodenoscopy (EGD) can be used to visualize evidence of reflux esophagitis (see the video below).

Severe distal reflux esophagitis, as seen via esophagogastroduodenoscopy. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.

Lundell et al confirmed gastroesophageal reflux disease (GERD) in patients with typical symptoms accompanied by endoscopic evidence of a mucosal break (defined as "an area of slough or erythema clearly demarcated from adjacent normal-appearing mucosa").[18] Endoscopic evidence of biopsy-proven benign peptic stricture or Barrett esophagus is also considered diagnostic evidence of GERD.[18]

EGD can be used to obtain biopsies that may help to determine the extent of esophagitis, Barrett esophagus, or other pathology. Interestingly, the EGD findings may be normal in as many as 70% of patients with GERD.

24-hour pH testing

Although pH testing is considered the criterion standard for diagnosis of GERD, routine use may be of only marginal benefit. It is best used in the absence of endoscopic evidence of reflux or when the diagnosis is unclear.[19] This test allows the physician to quantify the number and duration of reflux episodes, differentiate between upright and supine reflux, and correlate these events with subjective symptoms. Either 24-hour ambulatory esophageal pH-metry or the 48-hour wireless esophageal pH-monitor probe can be used.

Esophageal manometry

Esophageal manometry tests the function of the esophagus by evaluating peristalsis and lower esophageal sphincter pressure. Specifics about the length, location, and tone of the lower esophageal sphincter can be characterized. This test also helps diagnose underlying motility disorders, which may be a contraindication to fundoplication.

Preoperative manometry testing suggestions vary. Many physicians advocate preoperative manometry testing, noting that approximately 10% of manometry findings alter surgical planning.[19] However, the literature does not support mandatory preoperative manometry testing. Rather, manometry may be considered in patients who do not respond to empiric medical treatment and have normal findings on endoscopy.[7, 20, 21, 22]

Contrast radiography

An upper gastrointestinal series may be useful for anatomic delineation of the gastroesophageal junction in relation to the hiatus. This allows detection of hiatal hernias, strictures, or shortened esophagus. Esophageal peristalsis can also be qualitatively assessed.[7]

Impedance monitoring

Impedance monitoring evaluates esophageal motility and function through assessment of directional bolus transit within the esophagus. This test is particularly helpful in evaluation of nonacidic reflux.[23]

Gastric emptying tests

Gastric emptying tests may be considered if patients have a history of diabetes, severe nausea or vomiting, or postprandial bloating. In addition, they may be helpful in cases of reoperation. Gastric emptying studies should not be routinely obtained, because there is only limited evidence in the literature to support a correlation between gastric emptying test results and postoperative outcomes from fundoplication.[7]

 
 
Contributor Information and Disclosures
Author

Nicole E Sharp, MD Resident Physician, Division of General Surgery, Scott and White Memorial Hospital, Texas A&M Health Science Center College of Medicine

Nicole E Sharp, MD is a member of the following medical societies: American College of Surgeons, Association for Surgical Education, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

F Paul (Tripp) Buckley, III, MD, FACS Director, Division of General Surgery, Surgical Director, Heartburn and Reflux Center, The Scott and White Clinic; Assistant Professor of Surgery, Texas A&M Health Science Center

F Paul (Tripp) Buckley, III, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Surgical Education, Southwestern Surgical Congress, Michael E DeBakey International Surgical Society, Texas Surgical Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Torax medical<br/>Received grant/research funds from Covidien for speaking and teaching; Received consulting fee from Torax Medical for speaking and teaching.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases thank Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.

References
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  2. Ip S, Bonis P, Tatsioni A, et al. Comparative Effectiveness of management Strategies For Gastroesophageal Reflux Disease- Agency for Healthcare Reasearch and Quality Comparative Effectiveness Reviews, No 1. Report No: 06-EHC003-EF. Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Dec. [Full Text].

  3. Boccia G, Manguso F, Miele E, Buonavolonta R, Staiano A. Maintenance therapy for erosive esophagitis in children after healing by omeprazole: is it advisable?. Am J Gastroenterol. 2007 Jun. 102(6):1291-7. [Medline].

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  6. Goeree R, Hopkins R, Marshall JK, et al. Cost-utility of laparoscopic Nissen fundoplication versus proton pump inhibitors for chronic and controlled gastroesophageal reflux disease: a 3-year prospective randomized controlled trial and economic evaluation. Value Health. 2011 Mar-Apr. 14(2):263-73. [Medline].

  7. Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. 2010 Nov. 24(11):2647-69. [Medline].

  8. Malhi-Chowla N, Gorecki P, Bammer T, Achem SR, Hinder RA, Devault KR. Dilation after fundoplication: timing, frequency, indications, and outcome. Gastrointest Endosc. 2002 Feb. 55(2):219-23. [Medline].

  9. Peters MJ, Mukhtar A, Yunus RM, Khan S, Pappalardo J, Memon B. Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery. Am J Gastroenterol. 2009 Jun. 104(6):1548-61; quiz 1547, 1562. [Medline].

  10. Ip S, Tatsioni A, Conant A, Karagozian R, Fu L, Chew P, et al. Predictors of clinical outcomes following fundo;lication for gastroesophageal reflus disease remain insufficiently defined: a systematic review. Am J Gastroenterol. Mar 2009. 3:752-758.

  11. Salminen P. The laparoscopic Nissen fundoplication--a better operation?. Surgeon. 2009 Aug. 7(4):224-7. [Medline].

  12. Patterson EJ, Herron DM, Hansen PD, Ramzi N, Standage BA, Swanström LL. Effect of an esophageal bougie on the incidence of dysphagia following nissen fundoplication: a prospective, blinded, randomized clinical trial. Arch Surg. 2000 Sep. 135(9):1055-61; discussion 1061-2. [Medline].

  13. Mathavan VK, Yuh JN, Marks JM. Long-term evaluation of patients undergoing laparoscopic antireflux surgery without bougie placement. J Laparoendosc Adv Surg Tech A. 2009 Feb. 19(1):7-12. [Medline].

  14. Donahue PE, Samelson S, Nyhus LM, Bombeck CT. The floppy Nissen fundoplication. Effective long-term control of pathologic reflux. Arch Surg. 1985 Jun. 120(6):663-8. [Medline].

  15. DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Ann Surg. 1986 Jul. 204(1):9-20. [Medline].

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  17. Ellis FH Jr. Open Nissen Fundoplication. Pearson FG, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, Urschele HC Jr. Esophageal Surgery. 2. Philadelphia, PA: Churchill Livingstone; 2002. 319-324 Chapter 20.

  18. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999 Aug. 45(2):172-80. [Medline].

  19. Waring JP, Hunter JG, Oddsdottir M, Wo J, Katz E. The preoperative evaluation of patients considered for laparoscopic antireflux surgery. Am J Gastroenterol. 1995 Jan. 90(1):35-8. [Medline].

  20. Fibbe C, Layer P, Keller J, Strate U, Emmermann A, Zornig C. Esophageal motility in reflux disease before and after fundoplication: a prospective, randomized, clinical, and manometric study. Gastroenterology. 2001 Jul. 121(1):5-14. [Medline].

  21. Yang H, Watson DI, Kelly J, Lally CJ, Myers JC, Jamieson GG. Esophageal manometry and clinical outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg. 2007 Sep. 11(9):1126-33. [Medline].

  22. Frantzides CT, Carlson MA, Madan AK, Stewart ET, Smith C. Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication. J Am Coll Surg. 2003 Sep. 197(3):358-63; discussion 363-4. [Medline].

  23. Castell DO, Vela M. Combined multichannel intraluminal impedance and pH-metry: an evolving technique to measure type and proximal extent of gastroesophageal reflux. Am J Med. 2001 Dec 3. 111 Suppl 8A:157S-159S. [Medline].

 
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Rossetti-Nissen modified fundoplication.
Nissen fundoplication.
Toupet partial fundoplication.
Hiatal dissection. Esophagus is encircled and retracted anteriorly, exposing posterior hiatus for dissection.
Hiatal repair. Sutures should be placed from posterior to anterior.
Hiatal repair.
Anterior wall of gastric fundus is passed behind esophagus with atraumatic Babcock forceps.
Rossetti-Nissen fundoplication.
Anatomy of lower esophageal sphincter.
Original Nissen fundoplication, as described by Dr Rudolf Nissen.
Severe distal reflux esophagitis, as seen via esophagogastroduodenoscopy. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
 
 
 
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