Long-term effects of anti-reflux surgery on the physiology of the esophagogastric junction

Abstract

Background: Studies performed shortly after anti-reflux surgery have demonstrated that the reduction of reflux episodes is caused by a decrease in the rate of transient lower esophageal sphincter relaxations (TLESRs) and a decrease in the distensibility of the esophagogastric junction (EGJ). We aimed to assess the long-term effects of surgical fundoplication on the physiology of the EGJ.

Methods: We included 18 patients who underwent surgical fundoplication >5 years before and 10 GERD patients who did not have surgery. Patients underwent 90-min combined high-resolution manometry and pH-impedance monitoring, and EGJ distensibility was assessed.

Results: Post-fundoplication patients exhibited a lower frequency of reflux events than GERD patients (2.0 ± 0.5 vs 15.1 ± 4.3, p < 0.05). The rate of TLESRs (6.1 ± 0.9 vs 12.6 ± 1.0, p < 0.05) and their association with reflux (28.3 ± 9.0 vs 74.9 ± 6.9 %, p < 0.05) was lower in post-fundoplication patients than in GERD patients. EGJ distensibility was significantly lower in post-fundoplication patients than in GERD patients. Recurrence of GERD symptoms after fundoplication was not associated with an increased number of reflux episodes, nor was it associated with an increased distensibility of the EGJ or an increase in the number of TLESRs.

Conclusion: More than 5 years after anti-reflux surgery, patients still exhibit a lower rate of TLESRs and a reduced distensibility of the EGJ compared with medically treated GERD patients. These data suggest that the effects of surgical fundoplication on EGJ physiology persist at the long term and underlie the persistent reduction of reflux events.

Keywords: Esophagus; Fundoplication; GERD; pH monitoring.

Fig. 1

Example of a transient lower esophageal sphincter relaxation (TLESR) which is associated with a reflux episode as measured by combined high-resolution manometry and pH-impedance monitoring. The continuous high-pressure zone of the lower esophageal sphincter is temporarily interrupted during which a reflux episode can occur. The dotted arrow indicates the direction of reflux. The white lines represent impedance channels and the reflux episode is characterized by a drop in impedance starting in the distal channel. The pH-channel is represented by the most lower graph and demonstrates an acidic reflux episode