Manometric characteristics of the gastroesophageal junction after anterior versus posterior partial fundoplication

Abstract

How best to surgically treat GERD is an unresolved issue. To increase our insights into the fundoplication procedures, functional consequences for the gastroesophageal junction of an anterior or a posterior partial fundoplication were studied by manometry. Patients were randomly selected from a larger study in a randomised comparison between posterior and anterior partial fundoplications. The manometric studies were done 12 months after respective procedures in 24 patients. The motor characteristics of the esophagus and lower esophageal sphincter (LES) function were determined by use of sleeve catheter manometry. The manometric characteristics of the esophageal body were similar in the study groups except for the ramp pressure. This was significantly higher in patients with posterior partial fundoplications. The posterior group had significantly longer total length (P < 0.02) as well as longer intra-abdominal portions (P = 0.07) of the LES while the basal tone, albeit numerically higher, did not reach statistical significance. Water-swallow induced LES relaxations reached lower nadir values in the anterior group (1.7 vs 2.7 mmHg). Gas distension triggered few transient LES relaxations in both study groups while common cavities were more frequently observed in those having an anterior partial wrap (P < 0.01). A posterior partial fundoplication is followed by manometric characteristics suggesting a well functioning antireflux barrier with some obstruction to bolus passage as well as restricted venting of air from the stomach. The manometric mechanisms behind the inferior reflux control achieved by a Watson type of anterior partial wrap has now been further elucidated.

Dysphagia and Gastroesophageal Junction Resistance to Flow Following Partial and Total Fundoplication

“…These findings are what we might expect intuitively and yet neither we, 5,15 nor others 16,17 have used a systematic approach to demonstrate these relationships.…”

“…GEJ relaxation can only be reliably recorded with a sleeve or with pressure sensors spaced at no more than 1 cm intervals. 20 Anderson et al 15 and Engstrom et al 16 used a catheter with a sleeve and also found these intraluminal pressures were elevated in proportion to the extent of fundoplication. However, these studies did not evaluate patients preoperatively and postoperative findings were not interpreted in the light of preoperative dysphagia.…”

Laparoscopic Anterior Versus Posterior Fundoplication for Gastroesophageal Reflux Disease

“…Three trials lacked double blinding 8,15,16,41,42 and 2 trials did not conceal allocation. 15,16,41,42 One trial did not report the method of sequence generation 15,16,42 and another study did not report loss to follow-up. 41 Four trials reported a sample size calculation.…”

“…8,14 Finally, 11 publications on 7 original RCTs [8][9][10][11][12]15,41 comparing laparoscopic anterior versus posterior fundoplication were identified. Eight publications [8][9][10][11][12]15,41,42 reported short-term results and 4 publications evaluated long-term outcome 12,14,16,17 (Fig. 1).…”

“…Two trials divided the short gastric vessels in the LPF group. 10,[14][15][16]42 One trial enrolled patients with esophageal dysmotility and included 11 patients of this subgroup in both arms (Table 1). 9,17 Patient characteristics and indications for surgical treatment are listed in Table 2.…”