Post-fundoplication contrast studies: is there room for improvement?

Abstract

Objective: Since the mid-1990s, laparoscopic fundoplication for gastro-oesophageal reflux disease has become the surgical procedure of choice. Several surgical groups perform routine post-operative contrast studies to exclude any (asymptomatic) anatomical abnormality and to expedite discharge from hospital. The purpose of this study was to determine the accuracy and interobserver reliability for surgeons and radiologists in contrast study interpretation.

Methods: 11 surgeons and 13 radiologists (all blinded to outcome) retrospectively reviewed the contrast studies of 20 patients who had undergone a laparoscopic fundoplication. Each observer reported on fundal wrap position, leak or extravasation of contrast and contrast hold-up at the gastro-oesophageal junction (on a scale of 0-4). A κ coefficient was used to evaluate interobserver reliability.

Results: Surgeons were more accurate than radiologists in identifying normal studies (specificity = 91.6% vs 78.9%), whereas both groups had similar accuracy in identifying abnormal studies (sensitivity = 82.3% vs 85.2%). There was higher agreement amongst surgeons than amongst radiologists when determining wrap position (κ = 0.65 vs 0.54). Both groups had low agreement when classifying a wrap migration as partial or total (κ = 0.33 vs 0.06). Radiologists were more likely to interpret the position of the wrap as abnormal (relative risk = 1.25) while surgeons reported a greater degree of hold-up of contrast at the gastro-oesophageal junction (mean score = 1.17 vs 0.86).

Conclusion: Radiologists would benefit from more information about the technical details of laparoscopic anti-reflux surgery. Standardised protocols for performing post-fundoplication contrast studies are needed.

Figure 1

(a) Barium swallow, anterior–posterior projection, of a Nissen 360° fundoplication in which the fundus of the stomach is completely wrapped around the distal oesophagus and (b) barium swallow with artistic overlay.

Figure 2

(a) Barium swallow, anterior–posterior projection, of a 180° anterior fundoplication, in which the fundus of the stomach is partially wrapped anteriorly around the distal oesophagus and (b) barium swallow with artistic overlay.

Figure 3

(a) Barium swallow, anterior–posterior projection, of a Type I migration of a Nissen 360° wrap, in which a portion of the fundoplication has herniated above the diaphragm but the gastro-oesophageal junction remains below the diaphragm and (b) barium swallow with artistic overlay.

Figure 4

(a) Barium swallow, anterior–posterior projection, of a Type I migration of a 180° anterior wrap, in which a portion of the fundoplication has herniated above the diaphragm but the gastro-oesophageal junction remains below the diaphragm and (b) barium swallow with artistic overlay.

Figure 5

(a) Barium swallow of a Type II migration of a Nissen 360° wrap in which the entire fundoplication including gastro-oesophageal junction has herniated above the diaphragm and (b) barium swallow with artistic overlay.

Figure 6

(a) Poor quality barium swallow in a patient who had undergone a 360° Nissen fundoplication the day before and (b) repeat barium swallow in the same patient in the supine position, demonstrating a Type II wrap migration.