Swallowing MRI-a reliable method for the evaluation of the postoperative gastroesophageal situs after Nissen fundoplication

Abstract

Purpose: To evaluate the diagnostic performance of swallowing MRI of the gastroesophageal junction (GEJ) in the postoperative care of patients after laparoscopic antireflux surgery (LARS) MATERIAL AND METHODS: In this institutional review board-approved prospective study, 79 symptomatic patients (mean age, 52.3 years; range, 26-80 years) were evaluated after laparoscopic Nissen fundoplication. MRI findings were correlated with revision surgery, endoscopy, and high-resolution manometry (HRM) as standard of reference. MRI was performed on a 3.0-T unit using T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences for anatomical assessment of the GEJ followed by dynamic MR swallowing (fast low-angle shot sequences). Four independent readers (two radiologists, two surgeons) rated 83 MR scans according to defined criteria, such as wrap disruption, slipping, recurrent hiatal hernia, and esophageal motility disorder.

Results: Wrap disruption was correctly diagnosed concordantly with the standard of reference in 87.8%, slipping in 81.5%, and recurrent hiatal hernia in 84.9% of the cases. For esophageal motility disorder, MRI interpretation was consistent with manometry in 66.2% of the subjects. Interobserver analysis showed substantial agreement for recurrent hiatal hernia (k = 0.703), moderate agreement for wrap disruption (k = 0.585), and fair agreement for motility disorder and slipping (k = 0.234 and k = 0.200, respectively).

Conclusion: MR swallowing readily depicts the major failure mechanisms of LARS and has good reliability even in non-experienced readers.

Key points: • MR swallowing accurately readily depicts the major failure mechanisms of laparoscopic antireflux surgery and has good reliability even in non-experienced readers. • It should be included in the preoperative workup for revision surgery after fundoplication. • It will be of great benefit to surgeons in considering and planning a reoperation.

Keywords: Fundoplication; GERD; Magnetic resonance imaging.

Fig. 1

Normal wrap appearance. A 56-year-old male; axial (a) and coronal (b) T2 HASTE sequences show the typical “pseudo-tumor” appearance of an intact fundoplication wrap (arrows)

Fig. 2

Wrap disruption. A 61-year-old male; axial (a) and coronal (b) T2 HASTE sequences showing complete wrap disruption. The typical “pseudo-tumor” is missed on the axial (a) and coronal (b) views (arrows)

Fig. 3

a–c Recurrent hernia. A 39-year-old male; axial, coronal, and sagittal T2 HASTE with parts of the stomach (arrow) located above the diaphragm (arrowhead)

Fig. 4

Wrap herniation. A 60-year-old male; T2 HASTE sequences in the coronal (a), axial (b), and sagittal (c) views show the entire wrap lies above the esophageal hiatus (arrows) with a concomitant recurrent hernia

Fig. 5

Slipping. A 49-year-old male; a–c dynamic, coronal T1w sequences during swallowing of a mixture of buttermilk and gadolinium-chelate show slipping of parts of the stomach (arrow on b and c). a shows the normal part of the distal esophagus (arrow on a) and c shows the intact wrap (asteriks) in the regular subdiphragmatic position